Robotic surgery

ABSTRACT

Teleoperative, partially automated, and fully automated robotic surgery systems and methods are described herein. These systems and methods relate to at least improvement of robotic movements, three dimensional tracking and pose correction for robots interacting with deformable objections, controlling and optimizing the redundant axis of a seven degree of freedom robotic arm, virtual robotic surgery and simulation, and task coordination and optimization for multi-robot surgery.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application claims priority to U.S. Provisional Patent ApplicationNo. 63/177,589 filed on Apr. 21, 2021, U.S. Provisional PatentApplication No. 63/177,593 filed on Apr. 21, 2021, U.S. ProvisionalPatent Application No. 63/177,596 filed on Apr. 21, 2021, U.S.Provisional Patent Application No. 63/177,597 filed on Apr. 21, 2021,and U.S. Provisional Patent Application No. 63/177,603 filed on Apr. 21,2021. The entireties of these applications are incorporated herein byreference.

BACKGROUND

Robotic surgery today is essentially purely teleoperative. That is, ahuman has full control over the motions of a surgical robot, and therobot has almost no ability to make decisions on its own. But by nature,humans are imperfect and thus so is their ability to teleoperate asurgical robot to the full extent of its capabilities. Moreover, asurgical robotic system's potential to perform fully- orpartially-autonomous surgical procedures is limited by an inability toadequately design, optimize, and execute safe and effective movements ofone or more robots for a given procedure, both pre-operatively and inreal time.

BRIEF SUMMARY

According to one example of the present disclosure, a system forevaluating treatment of a surgical target of a patient's soft tissueorgan comprises: an imaging system configured to obtain images of thepatient's soft tissue organ; and at least one controller configured to:receive a user input of a treatment trajectory on the images to resect aportion of the patient's soft tissue organ; and determine a scorerelated to a function of the patient's soft tissue organ based on thetreatment trajectory.

In various embodiments of the above example, the treatment trajectorycomprises a cutting trajectory; the images are real time intraoperativeimages; the score is a percentage of the organ being removed; the atleast one controller is further configured to identify a vasculaturewithin the patient's organ within the treatment trajectory, and thescore is a function of the portion of the vasculature being removedwithin the treatment trajectory; the score is a percentage of organfunction loss based on the treatment trajectory; the at least onecontroller is further configured to modify the treatment trajectorybased on the determined score; the at least one controller comprises atrained machine learning system configured to receive the treatmenttrajectory input by the user and to output the score; the trainedmachine learning system is trained with data comprising treatmenttrajectories and corresponding surgical outcomes of historical surgicaltreatments; the score is indicative of expected post-operative functionof the organ; determining the score includes determining long-term bloodflow through the organ; and/or the organ is a kidney, and determiningthe score includes determining a post-operative percentage of activenephrons in the kidney.

According to another example of the present disclosure, a methodcomprises: obtaining an image of a patient's soft-tissue organ throughan imaging device; receiving at least one proposed treatment trajectorythrough a user input device; and generating a score related to apost-operative function of the organ for each of the at least oneproposed treatment trajectory.

In various embodiments of the above example, generating the scoreincludes determining an estimate of long-term blood flow through theorgan; the organ is a kidney, and generating the score includesdetermining an estimated post-operative percentage of active nephrons inthe kidney; and/or receiving at least one proposed treatment trajectoryincludes receiving two or more proposed treatment trajectories, and themethod further comprises: providing a recommended treatment trajectorybased on scores for each of the two or more proposed treatmenttrajectories.

According to another example of the present disclosure, a non-transitorycomputer-readable storage medium encoded with instructions executable bya processor of a computing system comprises instructions to: obtain animage of a patient's soft-tissue organ through an imaging device;receive at least one proposed treatment trajectory through a user inputdevice; and generate a score related to a post-operative function of theorgan for each of the at least one proposed treatment trajectory.

In various embodiments of the above example, the instructions togenerate the score includes instructions to determine an estimate oflong-term blood flow through the organ; and/or the organ is a kidney,and the instructions to generate the score includes instructions todetermine an estimated post-operative percentage of active nephrons inthe kidney.

According to another example of the present disclosure, an apparatus fordetecting a surface of a patient's organ comprises: a flexible paneldeformable in three dimensions to a surface of the patient's organ; aplurality of spatial tracking sensors secured to the deformable panel; adetector configured to detect at least two of the spatial trackingsensors; and at least one controller configured to identify a locationof the at least two spatial tracking sensors.

In various embodiments of the above example, the deformable panelcomprises a deformable mesh; the deformable mesh comprises a continuousmaterial forming a grid pattern; the flexible panel comprises a materialhaving fibers, each of the fibers having an elastic length; the panelcomprises a bioabsorbable material; the panel comprises a material thatis cuttable; the panel is a bag; the panel is expandable; the panelincludes micro-barbs configured to maintain the panel onto the surfaceof the patient's organ; the plurality of spatial tracking sensorscomprise at least one optical sensor or ultrasound transmitter; theplurality of spatial tracking sensors includes an array of sensorssupported by a region of the panel; the array of sensors has a firstdensity, and the plurality of spatial tracking sensors includes a secondarray of sensors supported by a second region of the panel, the secondarray of sensors having a second density greater than the first density;the each of the plurality of spatial tracking sensors is a separateindividual sensor; the detector is a stereo-camera system or ultrasounddetector; the controller is further configured to generate a sensinggrid from the detected spatial sensors and to track tissue deformationof the patient's organ in real time during a surgical procedure; thecontroller is further configured to register the location of the atleast two spatial sensors with a real time operative image; and/or theapparatus further comprises a display configured to display the locationof the at least two spatial sensors and a position of an anatomicalfeature of interest of the patient's organ on the real time operativeimage.

According to another example of the present disclosure, a method ofrobotic treatment of a surgical target of a patient's soft tissue organcomprises: obtaining real time intraoperative images of the patient'ssoft tissue organ; creating a trajectory plan for a surgical instrumentto excise or reconstruct a portion of the surgical target of thepatient's soft tissue organ; excising the portion of the surgical targetusing the surgical instrument and based on the instrument trajectoryplan; providing real time deformation data indicating real timedeformation of an external surface of the patient's soft tissue organwith a plurality of position sensors on the surface of the patient'ssoft tissue organ; registering the deformation data onto the real timeintraoperative images; modifying the trajectory plan in real time basedon the real time deformation of the external surface of the patient'ssoft tissue organ; and controlling the surgical instrument in real timeaccording to the modified trajectory plan.

In various embodiments of the above example, modifying the trajectoryplan in real time is a function of both the real time deformation dataand an output of a machine learning system indicating future deformationduring removal of the patient's soft tissue organ; the method furthercomprises: robotically positioning an ultrasound probe, and obtainingthe real time intraoperative images with the ultrasound probe; themethod further comprises: robotically moving the ultrasound probe inreal time to change a field of view (FOV) of the ultrasound probe; theultrasound probe is moved during a surgical procedure; the ultrasoundprobe is positioned on the surface of the patient's soft tissue organ;the trajectory plan for the surgical target for the surgical instrumentto excise the surgical target comprises cutting the surgical target; thetrajectory plan for the surgical instrument to excise the surgicaltarget comprises ablating the surgical target; and/or the method furthercomprises: creating a reconstruction trajectory plan to reconstruct theorgan.

According to another example of the present disclosure, a method forrobotic excising of a surgical target of a patient's soft tissue organcomprises: obtaining real time intraoperative images of the patient'ssoft tissue organ; creating an excising plan for a surgical instrumentto excise a portion of the surgical target of the patient's soft tissueorgan; excising the portion of the surgical target using the surgicalinstrument and based on the excising plan; providing real timedeformation data indicating real time deformation of an external surfaceof the patient's soft tissue organ; registering the deformation dataonto the real time intraoperative images; modifying the excising plan inreal time based on the real time deformation of the external surface ofthe patient's soft tissue organ; and controlling the surgical instrumentin real time according to the modified excising plan.

In various embodiments of the above example, the modifying of theexcising plan comprises adjusting a trajectory of the surgicalinstrument; and/or the real time deformation data is obtained with aplurality of position sensors on the surface of the patient's softtissue organ.

According to another example of the present disclosure, a roboticsurgery system comprises: a surgical robot configured to excise aportion of a surgical target of a patient's soft tissue organ based onan instrument trajectory plan; a position sensing apparatus configuredto indicate real time deformation of an external surface of thepatient's soft tissue organ; a camera configured to obtain real timeintraoperative images of the patient's soft tissue organ; and at leastone controller configured to: determine real time deformationinformation of the external surface of the patient's soft tissue organbased on the position sensing apparatus, register the real timedetermination information to the real time intraoperative images, modifythe trajectory plan in real time based on real time deformation of theexternal surface of the patient's soft tissue organ, and control thesurgical robot in real time according to the modified trajectory plan.

In various embodiments of the above example, the position sensingapparatus comprises: a flexible panel deformable in three dimensions tothe external surface of the patient's organ, and a plurality of spatialtracking sensors secured to the deformable panel; the system furthercomprises: an ultrasound probe, wherein the camera is an ultrasoundcamera of the ultrasound probe; and/or the position sensing apparatuscomprises: at least one optical sensor and a stereo-camera systemconfigured to detect the optical sensor, or an ultrasound transmitterand an ultrasound detector configured to detect the ultrasoundtransmitter.

According to another example of the present disclosure, a surgicalsystem comprises: an imaging system configured to obtain real timeintraoperative images of a patient's soft tissue organ; at least onecontroller configured to generate a rendered virtual model overlayed onto the real time intraoperative images; and a display configured todisplay the rendered virtual model overlayed on to the real timeintraoperative images, wherein the rendered virtual model includes apredefined avoidance region within an anatomy of the patient rendered ina first visual manner, and a predefined acceptable region within theanatomy of the patient rendered in a second visual manner.

In various embodiments of the above example, the rendered virtual modelincludes a surgical path rendered in the second visual manner or in athird visual manner; the at least one controller is further configuredto include a cut margin in the rendered virtual model; the systemfurther comprises a surgical robot, wherein the at least one controlleris further configured to determine a location of a surgical instrumentof the surgical robot relative to the anatomy of the patient; the systemfurther comprises an output device, wherein the at least one controlleris further configured to alert a surgeon via the output device when thelocation of the surgical instrument is within a predetermined range ofthe avoidance region; the at least one controller is further configuredto control the surgical robot to avoid the avoidance region when thelocation of the surgical instrument is within a predetermined range ofthe avoidance region; the system further comprises: a first roboticsurgical tool, and a second robotic surgical tool, wherein the at leastone controller is further configured to: receive a predefined avoidanceregion with an anatomy of a patient, receive a real-time location of thefirst surgical tool, receive a real-time location of the second surgicaltool, receive a predefined surgical space outside of the patient, andprovide an error warning based upon a real-time location of the secondsurgical tool relative to the avoidance region, the real-time locationof the first surgical tool, and the predefined surgical space outside ofthe patient; the error warning provides a remedial action to avoid acollision of the second surgical tool with the avoidance region, firstsurgical tool and/or the predefined surgical space; and/or the systemcomprises an imaging system obtaining real time intraoperative images ofa soft tissue organ of a patient and the virtual model of at least apart of one of the first robotic surgical tool and second roboticsurgical tool superimposed on the real time intraoperative image.

According to another example of the present disclosure, a surgicalsystem comprises: a first robotic surgical tool; a second roboticsurgical tool; and at least one controller configured to: receive apredefined avoidance region with an anatomy of a patient; receive areal-time location of the first surgical tool; receive a real-timelocation of the second surgical tool; receive a predefined surgicalspace outside of the patient; and provide an error warning based upon areal-time location of the second surgical tool relative to the avoidanceregion, the real-time location of the first surgical tool, and thepredefined surgical space outside of the patient.

In various embodiments of the above example, the error warning providesa remedial action to avoid a collision of the second surgical tool withthe avoidance region, first surgical tool and/or the predefined surgicalspace; and/or the system comprises an imaging system obtaining real timeintraoperative images of a soft tissue organ of a patient and thevirtual model of at least a part of one of the first robotic surgicaltool and second robotic surgical tool superimposed on the real timeintraoperative image.

BRIEF DESCRIPTION OF THE SEVERAL VIEWS OF THE DRAWING

FIG. 1 is a schematic representation of a robotic surgery system,particularly utilizing a coordinator-dependent framework for thecoordination of movements of multiple robots.

FIGS. 2A, 2B, 2C, and 2D illustrate example cuts to excise a tumor froma kidney.

FIGS. 2E and 2F illustrate an example mesh having position sensorssecured thereto on a kidney.

FIG. 3 illustrates a method for optimizing surgical robot movements.

FIG. 4 is a schematic representation of the capacitive detection oftouch with surgical instruments.

FIGS. 5A and 5B illustrate a first example effect of deformable bodieson robot trajectory.

FIGS. 6A and 6B illustrate a second example effect of deformable bodieson robot trajectory.

FIG. 7 is a flow diagram illustrating a method for synchronizing imagingto control surgical robots for real-time compensation of deformablebodies.

FIG. 8 illustrates the wholistic information used for controlling robotmovements.

FIG. 9 is an illustration of the projection of a 3-dimensional positionof an object in an external reference frame to a 2-dimensional roboticarm angle plane in the robot's reference frame.

FIG. 10 illustrates a method for determining an arm angle of a robot.

FIG. 11 is a flow diagram illustrating a method for determining velocitycontrol of a robotic arm.

FIG. 12 illustrates the relationship between activities, surgemes, anddexemes.

FIG. 13 illustrates dexemes, surgemes and activities in an exampleprocedure.

FIG. 14 illustrates a process of a pre-operative platform for autonomousor robot-assisted surgical procedures.

FIGS. 15A and 15B illustrate example surgical procedure flow charts.

FIG. 16 illustrates an example process for achieving the proper scaleand accuracy for a virtual model of patient-specific anatomy.

FIG. 17 illustrates full range and functional workspace areas of robotsand end-effectors.

DETAILED DESCRIPTION OF THE DRAWING

Briefly, the present disclosure relates to a robotic surgery system 100and associated methods that address current limitations in the art. Asillustrated in FIG. 1, such a system includes one or more controllers102, 104 (including e.g., one or more processors) that control one moresurgical robots 106 according to the methods described herein. The oneor more controllers 102, 104 may be located locally or remotely withrespect to the robots 106. In the example of FIG. 1, and as described inmore detail below, a coordinator controller 102 centrally controls oneor more dependent controllers 104, which each individually control acorresponding robot 106. The robots 106 and the controllers 102, 104 mayall communicate with each other by various means, including wired andwireless communication. For example, communication may be facilitated byWIFI, Bluetooth, near filed communication, direct peer-to-peercommunication, and the like, over a local area network, wide areanetwork, the Internet, and the like. In some specific examples,communication can be via ethernet using a combination of shared networkvariables, user datagram protocol (UDP), UDP Multicast, and/ortransmission control protocol (TCP) communication protocols.

Each surgical robot 106 is configured to interact with a patient 108with various surgical instruments (e.g., scalpels, clamps, electrodes,and the like). The robots 106 may include one or more servos, steppermotors, and like actuators (linear and/or rotary) for controlling one ormore degrees of freedom of an arm holding the instrument. Theseinstruments (and the robots themselves), and sensors associated with thepatient 108, may provide feedback to the controllers 102, 104, such thatthe feedback and other control information is used to determine outputsthat effectuate controls of the robots 106 and the instruments. Any ofthe controllers 102, 104 may be configured to execute any of thebelow-described aspects of the present disclosure.

Medical personnel (e.g., a surgeon) 110 may interact with and controlany of the robots 106 via a human machine interface (HMI) 112. As shownin FIG. 1, the HMI 112 provides interaction with the coordinatorcontroller 102. However, in other embodiments, the medical personnel 110may interact with any of the robots 106 individually via an associatedrobot-specific HMI.

It is noted that FIG. 1 represents only one architecture framework forcontrolling surgical robots. Of course, other architectures may be usedwithin the scope of the present disclosure. Further, any of the notedcontrollers can be configured to perform any of the methods and analyses(e.g., implement any of the machine learning systems) of the presentdisclosure. Further it is noted that some embodiments of the presentdisclosure relate to real time interaction with and control of therobots 106 (e.g., during a surgical procedure). As used herein, the term“real time” refers to a time period in which a person (such as a surgeonor other medical personnel) could not practically perceive any lag. Forexample, operations conducted in real time may occur within 500 ms ofeach other, within 450 ms of each other, within 400 ms of each other, orwithin 200 ms of each other.

According to one aspect of the present disclosure, the robotic surgerysystems and methods herein can leverage machine learning and artificialintelligence (or other models and like algorithms executed by one ormore processors) to improve surgical planning software and roboticsurgical control systems. This is accomplished through the analysis ofdata collected from both simulated and actual surgical procedures togenerate metadata useful for training, evaluation, planning, and thecreation of performance reports. More particularly, data from pastsimulated and executed surgical procedures is input into a machinelearning system, which is trained to output feedback to a surgeon and tothe robotic system itself. The input data may include information aboutthe surgical procedure (e.g., patient data, type of surgery, and thelike), information about the surgical robots (e.g., actuator movementsand associated goals of each movement, instrument responses tomovements, and the like), and outcomes (e.g., whether movements weresuccessful, whether additional force was required to achieve goal, andthe like). The output feedbacks may include suggested movements, controlsignals for the actuators, notices to a surgeon, and the like.

In other words, the machine learning systems according to this aspectrelate to the improvement of surgical planning simulations of the realworld, the generation of effective surgical movements, the control ofsurgical robots, and a human surgeon's creation of planned surgicalprocedures. Accordingly, the systems address the inability of currentrobotic surgery systems, surgical simulations systems, and pre-operativeplanning systems to improve themselves automatically.

In one example, the machine learning system is configured to improvepre-surgical planning simulations. The efficacy of a simulation of asurgical procedure relies on its resemblance to the real world (e.g.,the accurate representation of material properties and physics tosimulate the cutting action of a scalpel on a kidney). These features ofa simulation rely on models that represent real world systems. Forexample, constitutive models represent real world physical interactionbetween objects, visual models represent the appearances of objects, andbiofunction models can be used to represent the reaction of patientvitals to stimuli. These models can be based on algorithms withnumerical constants that can be tuned.

The machine learning system can be trained to analyze recorded roboticsurgeries, where the input data comprises extracted information fromrobotic movements, sensor data, and camera imagery to infer informationabout the real world. This can help improve the simulation's portrayalof the material properties of the tissues operated on by surgical robotsor the response of a patient's heartrate to hemorrhaging. The output ofthe machine learning system can also control the robot, for example bycontrolling joint compliance in an improved manner.

More particularly, the trained machine learning system can analyze theaggregate outcome of individual movements or groups of movements of thesurgical robot (based on the information from prior surgeries andsimulations) to determine if those movements or groups of movementsaccomplished what was expected. If the analysis results are suboptimal,the trained machine learning system can output more successfulmovements. For example, for an input of given movements, the trainedmachine learning system can output a classification of the result ofsuch a movement. Where that classification matches a desired result, theinput movement can be accepted as satisfactory. Alternatively, if theclassification does not match a desired result, the input movements maybe iteratively adjusted until the desired result is output. In someembodiments, the machine learning system may receive an input result andbe trained to output corresponding movements to achieve that result.

According to some embodiments, the machine learning systems can betrained to output a change to an organ's functionality resulting from asurgical procedure. This change may be a score of the resulting organfunction. For example, the excision of a tumor may be predicted toreduce kidney function by 25% given the desired trajectory plan toremove the tumor. In one particular example, the system is trained toestimate how cuts, excisions, or reconstructions made on an organ willchange its functionality based on the principle that cutting an endartery will prevent certain areas of an organ from getting blood flowand, in turn, change the organ's functionality. Further, the system maybe trained to consider the time to execute the operation, since a longerprocedure may result in more tissue subject to ischemic events (e.g.,from clamping of vasculature) that ultimately affect organ function. Inaddition to consider the above-noted volume loss, vasculature loss, andtime of procedure, the system may also be trained to consider cutmargins, area of the procedure, and suturing techniques in determining aresulting organ function score. Accordingly, the system can estimate therisk and resulting organ function, and even be trained to suggest newcutting, excision, or reconstruction trajectories.

As seen in the example of FIGS. 2A and 2B, end arteries extend into atumor 200 of a kidney. A potential cut 202 to excise the tumor 200 shownin FIG. 2A is 1 mm from the tumor 200, while a potential cut 204 shownin FIG. 2B is 2 mm from the tumor 200. The resulting compromised endarteries and the section of the kidney that loses functionality is shownby the shaded region 206. As can be seen, the cut 204 farther away fromthe tumor 200 results in a cut below a branch in the end artery. This inturn causes the kidney cut according to FIG. 2B to lose a higherpercentage of functionality. Considering this, by being trained withdata relating to the vasculature structure of the kidney, a machinelearning system can output a predicted end functionality of the kidneybased on an input cut trajectory.

Put another way with reference to FIGS. 2C and 2D, the machine learningsystem may be trained to determine or calculate a score associated witha proposed treatment trajectory 208 for excising a tumor 200. The scoremay be indicative of the effectiveness of the proposed treatmenttrajectory 208, and may be indicative of the remaining post-operativefunction of the organ. In this regard, the score may be a percentage offunction remaining or a percentage of function lost due to the treatmenttrajectory 208. In another example, the score may be a percentage of theorgan remaining or removed. In other examples, the score may beindicative of the parenchymal mass of the organ remaining or removed.

In one example, an imaging system may be used to identify a vasculature210 within the organ. In this regard, the score may be associated with apercentage of the vasculature 210 that is removed. In certain cases,certain portions of the vasculature 210 may lose post-operative functionimmediately following the procedure, but that portion of the vasculaturemay recover function in the long-term. In this regard, the machinelearning system may take into account an expectation of such recovery offunction in determining the score. Thus, the system may use long-termblood flow through the organ as a factor in determining the score.

The treatment trajectory 208 can result in the cutting of a blood vesselthat may supply blood (through smaller blood vessels) to a large portionof the organ, referred to as devascularization. In other words, cuttingof a blood vessel may eliminate blood flow to another portion of theorgan. For example, cutting off of blood flow through a large bloodvessel may affect 50% or more of the organ corresponding to the portionof the vasculature dependent on the large blood vessel being cut. Inthis regard, the machine learning system may use the information fromthe imaging system to estimate the percentage of the organ affected bydisruption of blood flow through a particular portion of thevasculature. A user may use the estimate from the controller todetermine whether the proposed treatment trajectory 208 is acceptable.

Further, the machine learning system may determine whether and to whatextent cutting of a particular blood vessel may affect blood flow to aportion of the organ that is not intended to be excised. For example,the proposed treatment trajectory 208 may be intended to excise a firstportion 210 of the organ defined by the interior of the trajectory 208,while intending to preserve a second portion (e.g., the remainder of theorgan). However, in some cases, the proposed treatment trajectory 208may cut a blood vessel 214 which supports blood flow to at least a partof the second portion (e.g., the non-excised portion of the organ).Thus, while a large portion of the parenchymal mass of the organ may bepreserved, only a portion of the remaining parenchymal mass may havesufficient blood flow. Thus, the score determined by the controller mayreflect not only the percentage of the organ remaining, but also thepercentage which will continue to receive blood flow, thereby basing thescore on the percentage of functional organ remaining post-operatively.

In some examples, the controller may be provided with multiple proposedtreatment trajectories. In such cases, the controller can determine ascore for each of the proposed treatment trajectories and, by comparingthe scores, provide a recommended treatment trajectory to the user.

In some cases, the controller may determine that the scores for thevarious proposed treatment trajectories are not acceptable. In suchcases, the controller, in conjunction with the machine learning system,may modify a proposed treatment trajectory to achieve an improved scorecompared to the originally proposed trajectories. For example, thecontroller may receive a first proposed treatment trajectory 132, butmay determine that the score for the first proposed treatment trajectory132 is unacceptable. The controller can access the machine learningsystem and identify a second treatment trajectory 134 which improves thescore to an acceptable level.

According to the example of FIGS. 2A-2D, the organ is a kidney. Kidneysfunction to filter blood that flows through the kidneys via the renalartery into a vasculature in which the renal artery branches intosmaller and smaller blood vessels. The smallest blood vessels reachnephrons within the kidney, and the nephrons filter the blood and directthe filtered blood to corresponding veins. In determining the score fora proposed treatment trajectory 208 for a kidney, the machine learningsystem may determine the amount of the vasculature that is to beremoved, taking into account any portion of the vasculature expected toregain function in the long term.

In some examples, the machine learning system may be trained todetermine a percentage of nephrons that remain functional or activepost-operatively. In this regard, the system may take into account thenephron density in regions of the kidney to be excised. For example, akidney may have regions of high nephron density and regions of lownephron density. The density of nephrons may correspond to the vasculardensity, with active nephrons corresponding to density of capillaries orother blood vessels. Accounting for the density of nephrons can affectthe score and associate the score with the post-operative functionalityof the kidney.

During a procedure, blood flow may be temporarily disrupted to theorgan, or at least a portion of the organ subject to a proposedtreatment trajectory 208, to allow the practitioner to perform theprocedure without excessive blood loss and to keep the region of surgeryfree from blood. If blood flow is disrupted for an extended period, theorgan or the vasculature within the organ may develop ischemia. In thisregard, the machine learning system can be trained to provide thepractitioner with an estimate of the time for which blood flow may besafely disrupted. For example, the system may use the proposed treatmenttrajectory to identify regions most susceptible to ischemia and, usingvarious factors, determine a safe length of time for disruption of bloodflow. The various factors may include the region and size of the organaffected or the amount of blood flow adjacent to the affected region.Additional factors may include the age, gender, and health of thepatient, as well as the health of the organ. The machine learning systemmay be trained to associate such factors, as well as historical medicaldata and other information provided by the user, with safe lengths oftime for the disruption of blood flow.

Following a procedure, the practitioner must perform renorrhaphy toclose an incision on the kidney. The suturing may be performed tominimize damage to the organ. In one example, suturing of the kidney maybe performed in two layers including base-layer suturing and corticalrenorrhaphy. In other examples, the practitioner may elect to performbase-layer suturing without cortical renorrhaphy. In other examples, thepractitioner may elect to forego suturing in favor of a tissue adhesivesuch as bovine serum albumin-glutaraldehyde tissue sealant, which mayresult in less damage than suturing.

As noted above, in some examples, the machine learning system may beprovided with multiple proposed treatment trajectories, for each ofwhich the system may output a score. In some examples, the system candetermine and provide to an estimated functionality of the organremaining post-operatively. For example, the system may indicate to theuser that the post-operative functionality of the organ is estimated at75% for a first treatment trajectory 216 and 85% for a second treatmenttrajectory 218.

In some examples, the machine learning system may indicate to the userif a proposed treatment trajectory will impact a critical region of theorgan. For example, the machine learning system may be trained torecognize regions of the organ that are associated with significant lossof functionality. Thus, if a proposed treatment trajectory will impactthis region, the system may indicate to the user that this region shouldbe avoided.

Further, the machine learning system may allow the controller to suggesttreatment trajectories based on input from the user and/or the imagingsystem. In this regard, the machine learning system may be input withinformation (e.g., images) indicative of the portion of an organ to beexcised. For example, the machine learning system may identify fromimages received from the imaging system regions of the organ that may beaffected by a cancerous tumor 200. Alternatively, or in addition, thesystem may receive as an input from the user an identification ofregions to be excised. The input from the user may be provided in theform of coordinates that identify the region or a graphical marking ofthe region to be removed.

The input from the user may include a minimum desired margin 220 withinthe region to be excised. Alternatively, the user input may include onlythe affected portion (e.g., cancerous tumor 200), and the user mayseparately indicate a desired margin 220. Similarly, when the machinelearning system identifies the region to be excised based on informationfrom the imaging system, the controller may add a margin 220. The marginmay be based on certain guidelines or on input received from the user.

Once the region to be excised (including the margin) is identified, themachine learning system may identify the one or more available treatmenttrajectories 216, 218. In this regard, the machine learning system mayalso present to the user additional information associated with eachproposed treatment trajectory 216, 218. For example, the system mayoutput a score associated with each treatment trajectory 216, 218 and/orremaining post-operative functionality of the organ with each treatmenttrajectory 216, 218.

In other examples, the region to be excised (e.g., tumor 200) determinedby the controller may not include a margin. In such cases, the user mayprovide the machine learning system with a minimum desiredpost-operative functionality. In these cases, the system may be trainedto associate the input functionality with a treatment trajectory thatmaximizes the margin 220 around the region to be excised while providingthe desired post-operative functionality of the organ. For example,along with indication of the region to be excised, the system mayreceive input from the user that 80% post-operative functionality isdesired. The machine learning system, being trained to associate thisinformation with potential trajectories, may then output the treatmenttrajectory 218 which provides 85% post-operative functionality whilemaximizing the margin 220 around the affected region 200. If the desiredpost-operative functionality is not achievable with any margin, thesystem can indicate to the user the maximum post-operative functionalityavailable with zero or minimal margin.

In some cases, in identifying available treatment trajectories, themachine learning system may take into additional information, eitherbased on input from the user or from the machine learning system. Forexample, as noted above, the machine learning system may identifycritical regions of the organ which should be avoided by the treatmenttrajectory. Similarly, the user may provide input to avoid certainregions. The machine learning system may use such information asconstraints in identifying available treatment trajectories.

As suggested above, the above machine learning system may be implementedon any of the controllers of the system 100, and may be implementedaccording to information association and analysis methods other thanmachine learning. As such, the above-described systems may beimplemented as a non-transitory computer-readable storage medium, suchas a memory device. In this regard, the non-transitory computer-readablestorage medium is encoded with instructions executable by a processor ofa computing system. For example, the instructions may cause thecomputing system to obtain an image of a patient's soft-tissue organthrough an imaging device, receive at least one proposed treatmenttrajectory through a user input device, and generate a score related toa post-operative function of the organ for each of the at least oneproposed treatment trajectory. Further, the outputs discussed herein(e.g., a score or proposed trajectory) may be provided to the user on adisplay device, such as HMI 112. Similarly, the systems can receiveinputs from the user through HMI 112 or other input devices.

In addition to the training discussed herein, the machine learningsystems in any of the discussed embodiments can be continually oriteratively trained. As such, the systems can continue to learn as theyare used and can be exposed to more patients, procedures, and outcomes.Additionally, such training may be based on synthetic experiences thatmay be generated from simulations using modeled systems. In someexamples, the machine learning systems can be trained with datacomprising treatment trajectories and corresponding surgical outcomes ofhistorical surgical treatments.

More generally, training a machine learning system with likephysiological information of a tissue and various cuts (or otherinstrument actions such as excisions and reconstructions), the machinelearning system can be trained to output a predicted result of theinstrument action. This physiological information may be derived fromanatomical models, imaging of the patient, and the like. Similarly, thesystem may be trained to accept a desired end result as an input andthus output an instrument action that achieves the result. Stillfurther, the system may be trained to analyze potential risks andrewards for various actions and output recommend procedures. Forexample, the system may compare the risk associated with excising toomuch tissue (e.g., cutting farther from a tumor and thus furtherdecreasing end organ function) with the risk of potentially leavingtumor tissue by cutting too close. Such system outputs may provide arecommendation to a user, or identify the relative risks and benefitsassociated with a plurality of cut lines (or other instrumentmovements).

Put another way, the machine learning system can be trained to analyze avirtual patient model and analyze the vessel structure of the patient,and then output estimated vessel structures correlated to organfunction. The system may also analyze proposed cuts and determine therelative risks of violating the tumor by cutting too close, ofcompromising the procedure, and of the change in organ functionalitybased on a given cut. This analysis can be applied to a plurality ofcuts, with the results of each cut presented to the user withestimations on each of the three risks, and/or a recommended cut. A user(e.g., a surgeon) can then weigh the tradeoffs and choose a final cut.Such a system can help improve patient outcomes by producing a reliableestimation of organ function based on cuts made on end arteries for agiven patient.

Still further, the machine learning systems can anticipate and predictuser decisions by recognizing common patterns. For example, the machinelearning system can use data from past operations to make “trajectorysuggestions” for the robot by recognizing common patterns of usage forcertain movements and contexts. The system can also analyze a particularuser's past or present use patterns in order to make predictions aboutwhat the user might want to do. Similarly, common errors may berecognized and automatically remedied. For example, where a pattern ofmovements suggests a result that may be harmful or otherwiseundesirable, such an output of the machine learning system may triggeran alert or warning.

Still further, the trained machine learning system may provide feedbackto users. For example, extracted information from a simulated orpre-planned surgical procedure, or from an actual prior procedure caninput to the machine learning system. The system may thus be trained tooutput an evaluation of that procedure by associating an input procedurewith known patient outcomes. Such outputs may include summary statisticsuseful in planning of patient care (time under anesthesia, expectedblood loss, etc.) or material planning for the surgery (powerconsumption expected, total cost of materials, etc.). These summarystatistics can be displayed in real time while the user is constructinga procedure. In addition, the system may agglomerate many summarystatistics together into a single measure or score of surgical resourceuse. Other outputs can include an expected patient outcome and/or asuggested optimization of the procedure for that predictor. For example,if a total length of sutures predicted by the trained machine learningsystem negatively correlates with good patient outcomes in a particularcontext, the output of the system may suggest optimizing the procedureto reduce the number of necessary sutures. In yet another example, theoutput of the machine learning system may be an evaluation of userperformance to verify user competence.

In still another example, a machine learning system can be trained toimprove the actual movement of a surgical robot. Such a system may beintegrated with, or informed by, the above- described simulation systemsused for pre-surgical planning. For example, the systems can controlmovement of the surgical robot according to particular trajectories toeffectuate the actions identified by the above-described pre-planning.

More particularly, control of electromechanical systems such as surgicalrobots depends on fine adjustment of the control parameters of theactuators of the robot. Analysis of past movement data and sensor datacan be used with iterative learning of the machine learning system toautomatically tune these parameters. Inputs to such a machine learningssystem may include patient vital signs, current robot states, and thelike; and outputs may include control signals to the robots and/ordisplays or like outputs identifying recommended movements to a user.Accordingly, the robot may be controlled according to the machinelearning system in real time. Such a system may be integrated with thesimulation systems described above, so that the surgical control systemcan adapt to expected circumstances rather than merely responding tocircumstances as they are currently.

For example, if a patient's blood pressure rises, that input isrecognized by the machine learning system, which is trained to output analert (or otherwise recognize) that the material properties of thekidney will change. Further, the machine learning system may then outputa signal that controls the robot to adjust force control gains to ensurethat the correct amount of force is used to make an incision in thekidney. According to another example, the machine learning system may beinput with information indicating that the patient is elderly and thusprovide control outputs that are limit force and speed due to fragiletissues of the patient. In response, the robots can be made to slow downand use less force.

Still further, specific movements of a surgical robot may be optimizedfor given procedures. Due to limitations such as human error, suboptimalreal time path planning, hesitation, and biomechanical constraints,robotic surgeries may include robot movements that serve no surgicalpurpose or are otherwise inefficient. Accordingly, machine learningsystems that improve control of surgical robots may be trained to do soby optimizing movements of the robot. In one example, such optimizationis performed by detecting and removing non-purposeful movements. Suchmovements may be determined based on a conceptual simplification andassumption that any movement that results in a change in the physicalcontact state between a surgical instrument and the patient is apurposeful movement. For example, the movement of a scalpel cut isfunctional only while the scalpel blade is physically touching tissue.Suturing movements only “do” something while the needle drivers areactively touching the needle or thread.

Based on these assumptions, movements executed by the surgical robot maybe optimized according to the method of FIG. 3. More particularly,surgical movements where touching begins, occurs, or ends have a highchance of being functional and thus are categorized as “purposefulmovements”. These movements remain unmodified. Outside of the abovefunctional movements, all other movements merely serve the purpose oftransporting the surgical instrument between active sites where touchinghappens, and thus are ripe for optimization. Such movements arecategorized as “transitional movements”. The transitional movements maybe optimized by using common motion planning algorithms based on layersof simple rules. For example, one optimum path may be a straight linepath between the last touch and the next touch. Another rule that may beapplied to the optimized movement may be to not collide with anythingwhen moving. Similar other rules may be utilized to optimize any path ofthese transitional movements. If a particular movement does not end orstart physical contact, it is identified as a “non-purposeful movement,”and can be eliminated (or alternatively, converted/merged into anoptimized “transition movement”). Finally, periods where there is nomovement at all may also be removed. This approach may be applied to anyset of surgical movements, for example, while planning for andoptimizing a robotic surgical procedure.

As the above disclosure for optimizing surgical robot movements can relyin part on detecting/identifying purposeful movements, another aspect ofthe present disclosure relates to systems and methods for detectingtouch of an instrument of a surgical robot, particularly on a patienttissue. There are a variety of sensing methods that can be fused toreliably sense touch. For example, force sensing may be applied, butforce by itself is limited because it cannot easily distinguish betweendifferent materials, and it struggles to detect materials that are softor liquid. Likewise, imaging or optical solutions can be employed, butthey are limited because of their inability to deal with occlusion.

However, capacitive touch sensors can detect the magnitude and positionof a capacitance change as measured by an oscillator when a conductiveobject enters the electric field of a capacitor driven by thatoscillator. Using this technique can distinguish between a human fingerand metallic or nonconductive objects based on the characteristicimpedance these objects present to the oscillator. A similar principlecan be applied to surgical instruments, as schematically illustrated inFIG. 4. As seen therein, an oscillating electric field is applied to thetip of a surgical instrument, and physical contact of that instrumentwith a conductive surface can be detected based on the load the surfacepresents to the oscillator producing that electric field. Because themagnitude of the loading depends on the impedance of the materialtouched, it is possible to differentiate between different materialsbased on a measured impedance. This can either be a measure ofconductivity (if touching conductive objects) or a measure ofpermittivity (if touching insulators). Such a system is operable withvoltages and currents that are of a safe magnitude for use in surgicalprocedures, and that avoid Ohmic heating, arcing, or cardiacdisturbances. In addition, efficiency and sensitivity of touch detectionfor specific materials may be further improved based on the frequency ofthe oscillator, which may be adjusted based on a desired surgicalcontext.

When touch is detected, systems and methods of the present disclosuremay further provide haptic feedback to the user. Without such haptic (orlike) feedback, it is impossible for a surgeon to know if accidentalcontact has been made if it is not apparent in a teleoperative visualfield of view. However, with touch information directly obtained fromthe robotic end effectors, it becomes possible to provide haptic (orlike) feedback to the surgeon directly proportional to the touch sensedby the end-effectors. In addition or alternatively to the hapticfeedback, the feedback may be audible, visual, or the like, which canalso provide the surgeon with relevant information regarding interactionof end-effectors with other objects (such as tissue). For example, asound intensity may be proportional to the touch pressure sensed by anend-effector. In another example, an object displayed on a screen (e.g.,a box) may change size, shape, color, brightness, or the like,corresponding to a level and type of touch sensed by the end-effectors.

Another aspect of the present disclosure relates to sensors formeasuring time-varying changes in the position, orientation, and shapeof instruments (or other objects) being manipulated during a procedure.Position information is currently obtained by surgeon visualization viaa camera and/or pre-operative imaging data providing context.

Positions of instruments or other objects attached to the end of asurgical robot arm may be estimated based on positional knowledge of therobot itself (e.g., from internal sensors of the robot). However, theseestimates become less precise for less rigid objects. It is in thiscontinuum of deformability that spatial tracking of all elements(anatomy and tools) becomes more difficult.

One approach to 3D tracking of deformable objects (instruments, objects,tissues, and the like) for surgical navigation includes a system havingspatial tracking sensors, a mesh to hold the sensors in a knownrelationship to an object of interest, and a corresponding processorconfigured to perform the real-time registration of the object to aknown reference frame for the surgical system. The sensors can be basedon any 3D spatial tracking techniques including optical, magnetic,thermal, radio-frequency (RF), ultrasonic, radioactive, and the like.Further, the sensors may be arranged on the mesh in an arbitrary patternor pattern other than an array in or across multiple regions of a singlemesh. Such variations may be desirable where spatial tracking is moredifficult or more desirable at one location that another.

For example, optical sensors may determine position with a stereo-camerasystem, where the position of the camera is in a known reference framerelative to the surgical system, and it detects passive reflective lightfrom a sensor, detects passive fluorescent light from a sensor coveredwith fluorescent dyes or proteins, detects active light (e.g. LED) froma sensor; and/or utilizes a variety of image processing algorithms(including machine learning and AI) to locate a point of interest in 3Dspace from video data. Similarly, thermal sensors can determine spatialposition by a stereo-thermal camera system, where the position of thecamera is in a known reference frame relative to the surgical system,and elevated temperature heat emitters are located in the field of viewof the cameras. Magnetic sensors can sense spatial position where theposition of the magnetic field emitters are in a known reference framerelative to the surgical system, and the individual sensors use themagnetic field strength to determine their location.

RF field spatial sensors can determine position by utilizing RF emittersin a known reference frame relative to the surgical system, and an RFreceiver to sense the strengths, phases, and the like of signals emittedfrom the individual RF emitters. Similarly, ultrasonic sensors can beused to determine position with a stereo-ultrasound system, where theposition of the detector is in a known reference frame relative to thesurgical system, and the individual markers emit signals that allow thedetector to determine their location based on their strength, phase, andthe like. And radioactive beads can be used to determine spatialposition with stereo-radioactive detector system, where the position ofthe detector is in a known reference frame relative to the surgicalsystem, and the individual radioactive markers emit low dose radiationdetected by the detector.

With reference to FIGS. 2E and 2F, the individual sensors 222 may beembedded in a grid-like mesh (e.g., to hold the sensors in an array) 224that can be attached to the organ (e.g., kidney in FIGS. 2C and 2D),surgical tools, or other anatomical items of interest. Accordingly, themesh 224 holds the sensors 222 on the surface of the object (e.g., anorgan or other patient tissue) being tracked. Although the sensors 222may be generally affixed to the mesh 224 in a grid or array, the densityof sensors does not need to be constant across the entire mesh. Rather,one region of the mesh may have a greater density of sensors thananother region.

In one example, attachment of the mesh to the patient can be in the formof a bag that wraps around and is cinched in place to track an organsuch as the kidney. The mesh also can be in a form where it attachesdirectly to tissue with a micro-barbed surface. The relativerelationship between the sensors does not need to be maintained by themesh. Rather, the mesh fibers can be stiff or elastic along theirlength, or otherwise deformable in two or three dimensions. In otherforms, the mesh may include expandable elements (e.g., such as with anexpandable stent that takes size of lumen) so that it may be placed in avessel, or have a C-shaped design and be placed on the outside of avessel with nitinol rings used to wrap and retain grip on vessel. Themesh can also be made bioabsorbable and/or biodegradable, so that fiberscan be left in the body following the surgery. If the individual sensorsare passive (e.g., do not have wires attached) then the mesh can be cutto fit the anatomy. If the sensors have wires, or the mesh otherwisecannot be cut, individual smaller-sized meshes can be patched to cover adesired area.

So that key anatomy and patient specific geometry of the object beingtracked (e.g., an organ) is known a priori, anatomical imaging (e.g.,MM, CT) data can be pre-processed into a 3D model. Real-time positionsfor each sensor of the mesh as determined by a processor based onsignals from corresponding detector(s) can then be registered with the3D model. This registration can be based on best fit techniques toestablish an estimate of the location of the organ, surgical tools, orother items of interest in the known reference frame of the surgicalsystem. Additionally or alternatively, registration of the sensor datamay be made to real time intraoperative (rather than pre-operative orlike a priori) images.

In one embodiment, the above-described sensors and mesh can be used forsurgical navigation and tracking. Example navigational uses include amesh bag around the kidney, where registered sensor positions or used togenerate a grid to locate relevant anatomical structures relative tosurgical tools. This registration can be used to aid a surgeon cuttingaround a tumor. The mesh may also or alternatively be used as an overlayfor locating the tumor. In still other examples, the mesh and sensorsmay be used for rectal or prostate surgery. Example tracking usesinclude a mesh used to track deformation of a tissue, for example, as aninstrument (e.g., a scalpel) interacts with the tissue as described inmore detail below.

Considering the above, still another aspect of the present disclosurerelates to control of robotic systems during interaction with deformablebodies or rigid bodies. Deformable bodies may be the instrument(connected to the end effector of the robot) used by the robot, or thestationary body on which the robot works (e.g., a patient organ). Theinteraction between the robot/instrument and deformable body can berepresented by a model and/or monitored in real time for example throughthe use of the above-described mesh. In one example, the model creates avirtual ancillary sensor at the location on or within the deformablebody that is closest to the part of the instrument that will be incontact with the tissue. If the instrument is not actually in contactwith the body, then the model will output the projected nearest bodyposition.

This model may be an approximated constitutive model based onpreoperative imaging data, material properties such as elastic modulusand strain, force, position, constitutive parameters, the initialmorphology of the deformable body (e.g., its rest shape), sensor data,and other parameters. The rest shape can be a common rest shape derivedfrom any simulation, 3D printed surgery planning, and the actualprocedure. Using a common rest shape allows for space warping betweenthe surgical planning and the robot control. In order to perform spacewarping, the model is interrogated to get: 1) a virtual 6D ancillarysensor position of the nearest point on the deformable body relative tothe tool, 2) the same virtual 6D ancillary sensor position for the restshape of the deformable body, and 3) the relevant forces in thedeformable body coordinate system or as transformed to the virtualancillary sensor position.

Obtaining the parameters described above allows for space warping of aninitial trajectory of an instrument relative to a deformable body due todeformation. A robotic trajectory created for a deformable body uses adeformable body reference shape. Depending on the embodiment, thereference shape may be the rest shape. This trajectory specifies theposition control pose (PCP) between the robot instrument coordinatesystem and the reference deformable body shape, considering theinstrument is typically at the end of a robot. The body is eitherstationary or can move relative to a fixed coordinate system.

Space warping relies on the model output to continuously move thereference deformable body shape utilized by the trajectory to thelocation that provides the best estimate of where it would be after thedeformable body has changed shape. An example of this concept isillustrated in FIGS. 5A and 5B, where a robot 500 is programmed to drawa line on top of a board 502 with an instrument 504. In the scenarioshown in FIG. 5A, the board 502 has three supports 506 across its axiallength, so it does not deform or deflect as the robot 500 moves alongthe axial direction. The robot 500 is programmed purely in positioncontrol and moves along the axial direction of the board 502 andmaintains its position in all other degrees-of-freedom. However, in thescenario of FIG. 5B, the board 502 is only supported by two supports 504on one half of its length. Without the ability to warp space, theinstrument 504 would move to the right with no knowledge of the curvedsurface of the board 502. After the instrument passes over the secondsupport 806 from the left, it would stop touching the board 502 andwould be unable to perform its task. With space warping, however, theboard's reference shape would be projected to the location on the boardclosest to the robot instrument 504. Thus, as shown in FIG. 5B, theinstrument can follow the surface of the deformed board 502 tipping upon the left side and down on the right side. The instrument 504 is ableto follow the board's surface because it is constantly moving thereference shape to the current instrument position and using thereference shape's coordinate system to define the position control pose.In other words, the instrument takes on the reference shape's coordinatesystem so that the movement of the instrument matches that of thedeformation. This reference shape is shown in FIG. 5B overlaid on theoriginal body. Accordingly, the trajectory from FIG. 5A may be used toperform the task in the scenario of FIG. 5B.

A second example based on a kidney 600 and suturing instrument (e.g., aneedle) 602 is illustrated in FIGS. 6A and 6B. As seen in FIG. 6A,treating the kidney 600 as a rigid body allows the instrument 602 tosimply move around the perimeter of the kidney 600 according to itsknown shape. However, as shown in FIG. 6B, because the kidney 600 isactually a deformable body, as soon as the instrument 602 comes incontact with the kidney 600, the kidney 600 changes shape due to theforce (e.g., 10 N) applied. Without space warping, the programmedtrajectory of the instrument 602 would execute an incorrect series ofmoves because it will be operating under the assumption that the kidneyis always the same shape (as in FIG. 6A). Space warping, however, allowsthe instrument 602 to follow the initial trajectory made relative to thereference shape even as the kidney changes shape in real time. As above,FIG. 6B shows the kidney reference shape overlaid to show how it is usedto map the PCP used in the trajectory to the deformed shape of thekidney.

It is noted that the kidney in FIG. 6B is assumed to be a completelyelastic material, such that it returns to its original shape after theexternal force is removed. If the body is not elastic, then it would notgo back to the initial shape. For accurate repeatability and/ordeterminism in robotics with deformable objects it can be preferred tohave more information than just the PCP to execute a trajectory. While aposition control pose between these two rigid bodies completelydescribes their spatial relationship, when space warping is introducedto account for deformation of the instrument or other body, a positioncontrol pose can have infinite solutions. For example, FIGS. 6A and 6Bcan describe the same position control pose. However, as a function ofmaterial properties or contact force, the deformable body can deform inmany different ways. This is desired behavior of the position controlpose when trying to put the instrument tip at a specific location on theobject in the presence of deformation. However, it means that for agiven position control pose, there is not a unique solution for wherethe instrument should be. In turn, this means that in order to havedeterministic playback of the instrument's motion relative to thedeformable body, the position control pose alone may not be enough, andother process variables may be needed. Such variables may include theforces exerted by the instrument on the body, and/or the absoluteposition of the instrument relative to the body (an absolute positioncontrol pose).

These process variables allow robots to correctly execute what wasintended during a planning or simulation of a procedure. Fordeterministic playback to work in the presence of deformable objects,the position control pose and forces should be replicated, or theabsolute position control pose should be replicated. Differences betweendeformations in vivo, in vitro, and in silico, may be present because oferror in modeling and/or material property differences with eachmodality. Therefore, when transitioning from a simulation or test to anactual procedure, the position control pose forces may be played back toget a similar mechanical response out of the system. Thus, a uniquecontrol scheme for the position control pose may utilize hybridforce/position control in several degrees-of-freedom when programmingtrajectories in one modality (typically in silico), and executing it inanother. Incorporating force yields an unambiguous relationship andunique position control pose.

If force control is not available or the robotic process is sufficientlyrepeatable (perhaps due to extremely repeatable deformable bodybehavior), then the absolute position of the instrument relative to thebody may be played back (i.e., the position without space warping).Absolute position playback is equivalent to the concept of superpositiontesting. Absolute position control pose may not work sufficiently whenrunning a trajectory in one modality and then switching to anothermodality. However, using absolute position control pose can providesufficient results when repeating procedures within the same modality(e.g., in vivo).

In short, there is desire to program a robot to execute a trajectory ona deformable body in real time as the deformable body deforms, toexecute the same trajectory on a deformable body in silico, in vivo, andin vitro, and/or to execute the same trajectory accurately on adeformable body whose behavior is not repeatable. The above-describedtechniques address these concepts.

Additionally, imaging technology can be utilized to compensate in realtime for tissue deformation, by automatically synching image recognitioncapabilities of different imaging modalities and surgical robots. Moreparticularly, multiple imaging modalities can be synchronized with eachother to form hybrid images. Real time images can be collected usingvarious modalities such as ultrasound, doppler, elastography, biometricimpedance, fluorescence imaging, thermal imaging, laser imaging, and thelike. High definition coaxial imaging can be collected from devices likeMRI, CT, PET scan, and the like. Digital tags can be used to markanatomical features on the coaxial image such as the center of a tumorin a prostate. Sensor data (e.g., from the above-described mesh) mayalso be registered to the images. When the intraoperative real-timeimages are collected, the data from the different modalities can beoverlaid to locate the anatomical feature defined by the digital tag inreal-time. In other words, the images from multiple modalities can beregistered to each other based on the digital tags of anatomicalfeatures, and further registered to real time sensor data collected froma mesh.

In the case of deformable objects, registration permits thepre-operative coaxial image to take on the deformed shape of the objectimaged by the intraoperative real-time images and visualized in thehybrid image. In this way, even though the pre-operative coaxial medicalimages are taken before the procedure and thus do not represent anydeformed anatomy, they can still be utilized to visualize deformedanatomy caused by cutting (including excising or reconstructing tissue),handling, and otherwise pushing of the patient's tissues once aprocedure starts. As a result, the hybrid images are more accurate andcompensate for tissue deformation in real-time. An example method forachieving this end is illustrated in FIG. 7.

According to the example of FIG. 7, prior to executing a procedure(e.g., a robotic prostatectomy), a pre-operative coaxial image such asan MRI is taken of the operative tissues (e.g., in and around apatient's prostate). The surgeon then defines a digital tag at thecenter of the tumor in the prostate in the MRI image. During theprocedure, an ultrasound probe (e.g., inserted into the rectum) collectsreal-time images of the tissue in different fields of view (FOV). Theintraoperative real-time images are combined with the pre-operative MRIimages and sensor data (e.g., from the above-described meshes 210)indicating any deformations to highlight the digitally tagged anatomicalfeatures. The surgery can then be completed with a teleoperated robothaving its trajectories modified automatically and in real time based onthe hybrid images as a reference (as described above). Such increasedaccuracy and improved control of the robot helps the surgeon avoid vitalstructures like the nerves in a prostatectomy.

In some embodiments the above analysis can be performed with a trainedmachine learning system. For example, such a system may be trained tooutput the hybrid image based on input co-axial and real-time images,sensor data (e.g., from the above-described meshes 210), and the like.Additionally or alternatively, the machine learning system may betrained to output control signals to the robot according to a trajectoryplan for the robot to perform a particular action based on a hybridimage, digital markers, and like inputs that avoid boundaries ofimportant anatomical structures.

The above-described method can be implemented according to varioussystem configurations. In one example, a passive ultrasound (or otherreal-time imaging) probe may be affixed to a stand inserted into therectum (or other object being imaged). The ultrasound probe and therobots may be synchronized via a central controller, such as thecoordinator 102. In another configuration, the main robot may include anadditional arm that is fitted with the intraoperative real time medicalimaging device (or like probe). Adding the dynamic element to the realtime imaging probe can increase the procedure's efficiency by allowingthe controller to adjust the probe to produce the best field of view toexecute any part of the procedure at any given time. The other arms ofthe robot can receive commands from the central controller andcompensate the field of view the probe produced to take into account thedeformation of tissues seen in the procedure. And according to a thirdexample, the central controller can command an additional roboticssystem. In other words, one robot can control the intraoperativereal-time medical imaging device and transmit data back to the centralcontroller, while a separate robotic system can control the procedure.

In a robotic partial nephrectomy example, a tumor or lesion is excisedfrom the kidney while the kidney's good tissues are preserved. In thisexample, fat around the kidney can be dissected to have visual contactwith the kidney's surface and, in some cases, the tumor or lesion'ssurface within the kidney. This can give easy access for a sensor meshto be placed into the patient to track the deformation seen on thesurfaces. In this example, the visible boundaries of the tumor are welldefined within the view of a primary robot scope, which can be used forreal time imaging and to generate the hybrid image. This scope may add alayer of redundancy and provide additional accuracy to the hybrid image.

The primary robot could also be affixed with an additional armcontrolling an intraoperative real time medical imaging device thatwould be positioned on the surface of the kidney. This robot couldautomatically center the field of view, scroll, and be able to zoom inand out to optimize the image with respect to the tumor. The additionalarm then can utilize the pre-operative coaxial images, intraoperativereal time images, and tissues deformation sensor data to produce thehybrid image. The key anatomical features in the hybrid image can bedefined and used to guide the procedure and/or utilized as feedback tooptimize the field of view of the additional arm of the robotcontrolling the intraoperative real-time images.

Similar to above, one or more additional robots could be controlled by acentral controller such as the coordinator 102, with the intraoperativereal time medical imaging probe be affixed to a second robot. Again thissystem can be synchronized through the central controller to utilizepre-operative coaxial images, intraoperative real-time images, andtissues deformation sensor data to produce a hybrid image that be usedto generate trajectory controls in real time for all the robots in thesystem. The robot that has the intraoperative real time medical imagingprobe can optimize its view by translating, zooming and rotating toproduce the best field of view for the procedure at any given moment.

Further, as discussed above, a resulting organ function may be predictedand scored based on a given procedure. For example, the excision of atumor may be predicted to reduce kidney function by 25% given thedesired trajectory plan to remove the tumor. Such information may alsobe utilized by a controller or trained machine learning system of therobot to control the robot trajectories in real time or refinetrajectory plans prior to the procedure. For example, a machine learningsystem may also identify that a different trajectory plan to remove thetumor would only reduce kidney function by 20%, and thus adjust thetrajectory plan of the robot to the less destructive plan.

With reference to FIG. 8, control of surgical robots may be based onwholistic real-time information—that is, at least information related totissue deformation (e.g., based on models and/or real time tracking witha mesh) and current positioning of the robot combined with pre-operativeinformation and analysis (e.g., for generating hybrid images and/orpredicting procedure outcomes) of the patient (and organ) on which aprocedure is performed—to optimize and improve robotic movements duringthe procedure, and to improve outcomes. In other words, a controller ortrained machine learning system of the robot may rely on thepre-operative images, intraoperative images, hybrid images, and/orsensor data (e.g., from a mesh) to determine deformation and futureorgan function for a given trajectory of the robot during the surgery.All or any portion of this information may then be used to controltrajectories of the robot in real time to perform and optimize theprocedure.

Another aspect of the present disclosure relates to the precision andcontrol of robots manipulating objects in space. Generally, the positionand orientation of an object in space can be described as a sixdegree-of-freedom (DOF) relationship involving three translations (x, y,z) and three rotations about those axes. Most robots use six motors andlinkages between the motors to allow the robot to place the object atthe end of the robot (e.g., the instrument) in this 6-DOF space. For a6-DOF robot there is commonly only one pose (rotation angle ororientation of each of the six motors) that can place an object held bythe robot at a desired position and orientation in space.

Another class of robot has seven degrees-of-freedom, where the seventhdegree is a redundant axis. Redundant serial arm robots are capable ofmotions categorized as “self-motions” or “elbow swivels” in which thepose of the robot may change without effecting the end-effectorposition. For a 7-DOF robot, the redundant axis provides an infinitenumber of possible poses for a given end effector position (as definedin 6-DOF). With such robots, the pose can be modified to avoid jointlimits (motor angles at the top and bottom of their range),singularities (poses where motor rotation axes are aligned and themathematical control of the tool 6-DOF becomes ambiguous), andcollisions (e.g., while placing the tool at a specific position andorientation in space, the rest of the robot arm may run into surroundingstructures or moving objects, such as other robots or surgicalequipment, medical personnel, regions of the patient not intended to beoperated on, and the like).

The decision of what motor angle command to send to this redundant axisis typically left up to a robot programmer, a priori, through trial anderror. However, according to the present disclosure, the redundant axismay be controlled automatically without a priori knowledge of where theobject held by the robot is supposed to be.

Briefly, an example method for controlling the redundant axis calculatesa velocity that, when applied to the redundant axis of a 7-DOF serialarm robot, drives the robot away from singularities, joint limits, anddesignated spatial collision points while maintaining a constantend-effector position. Given current axis positions and a list of pointsin space that should be avoided, this method of control is able tocalculate a redundant axis velocity that will drive the robot to anoptimal pose. More particularly, the robot's current state of redundancycan be represented by an “arm angle” that ranges between −180° to +180°.This arm angle exists on a circle (hereinafter a “redundancy circle”)that lies on a reference plane (hereinafter an “arm angle plane”) thatcontains all possible locations for the manipulator elbow given thecurrent end-effector Cartesian position. The position of the manipulatorelbow when the redundant axis is at 0 degrees is the reference positionfor the origin of the redundancy circle. Movement of the redundant axiswhile maintaining the end-effector position will result in movement ofthe elbow around the redundancy circle on the arm angle plane. The anglebetween the elbow at any given redundant axis angle and the 0 degreeelbow position is referred to as the arm angle.

As suggested above, there are three possible hazards in movement of arobotic arm that should be avoided: collisions, singularities, and jointlimits. First regarding collision avoidance, it can be difficult todefine which side of a boundary is forbidden to avoid collision due toambiguity in defining the robot's pose as a function of the Cartesianend-effector position. In other words, it can be difficult to determinean appropriate polarity to the determined collision avoidance velocity.However, this ambiguity can be resolved by applying a logical test tothe algorithm output. That is, given a pair of boundary arm angles A andB on the redundancy circle, there are 3 possible zones: Zone 1: The zonedefined by A-B; Zone 2: The zone defined by −180° to A; and Zone 3: Thezone defined by B to +180°. Because the current arm angle of the robotis known, and it is known that the robot cannot exist in forbiddenzones, the appropriate polarity can be identified. For example, if therobot is in Zone 2 or Zone 3, Zone 1 is forbidden; and if the robot isin Zone 1, then Zones 2 and 3 are forbidden.

For singularity and joint limit hazards, zones created from the jointlimits for each joint are intersected with the zones mapped fromsingularities in order to create a single set of zones. While existingfunctions used for avoidance of joint limits can be effective, thesingularity avoidance methods are not satisfactory when used inconjunction with the joint limit avoidance functions. Instead, areplacement function is described below. The general form of thesingularity avoidance function used in this method of robot control isgiven as:

$\Delta = {\frac{x - {buff}_{sing}}{{r_{sing}( {x - {buff}_{sing}} )}^{2}} - {tol}_{sing}}$

where Δ is the output of the function expressed as a change in arm angleof the robot, x is a current arm angle of the robot, buff_(sing) is abuffer around the singularity that modulates the reach of the avoidanceeffect of the function, r_(sing) is a reaction coefficient that drivesthe curvature (and hence the avoidance strength) of the function, andtol_(sing) is a threshold for a dead band where the singularity has noeffect on avoidance effort. Increasing the value of the buffer willcause the robot to react more aggressively further away from thesingularity, increasing the value of the reaction coefficient will causea stronger avoidance effort, and increasing the threshold increases thesize of the dead band.

The singularity avoidance function is asymptotic at its edges to ensurethat the robot does not wander into forbidden arm angle zones. However,for a collision avoidance function, the reaction cannot be asymptoticbecause the hazard is a physical object (or objects), which may movetowards (or away from) the robot. An asymptotic reaction results inintense avoidance reactions when near boundary conditions. Due to thisproblem, a softer function is described below.

In order to avoid an object (or anatomical region that should not betouched by the instrument held by the robot), the potential forcollision with the object can be mapped to the redundancy circle. Withreference to FIG. 9, this is accomplished by projecting the3-dimensional position of the object in an external reference frame(“World 1”) to the 2-dimensional arm angle plane which is defined in therobot's reference frame (“World 2”). Although in principle any axis of aredundant manipulator may be defined as the redundant axis, in thisexample Joint 3 of the robot is the redundant axis. In this arrangement,self-movement of the robot only results in a change in position of Joint4 (the “elbow”) to avoid collisions. The variables in the illustrationof FIG. 9 are defined according to Table 1, below:

TABLE 1 Variables of FIG. 9 Variable Meaning P_(J1), P_(J2), P_(J6), andP_(J7) Positions of joints 1, 2, 6, and 7 transformed to the World 1coordinate system P_(J4,R) World 1 position of the real robot joint J4P_(J4,V) World 1 position of the virtual robot joint J4 (when joint J3 =0°) O_(PSI) Arm angle orientation

Vector from joint J2 position to joint J6 position

Vector from joint J2 position to real joint J4 position

Vector from arm angle orientation to real joint J4 position

Vector from arm angle orientation to virtual joint J4 position A_(PSI)Arm angle: The angle between 

 and 

D_(arm) Distance from the origin to the circle of possible joint J4positions in World 1 D_(buff) Distance through which the collisionbuffer extends (user determined)

FIG. 10 illustrates an example method for determining an arm angle basedon the above hazard avoidance discussion. According to this method,collision avoidance can be completely agnostic to a task an instrumentheld by the robot is engaged in, and can operate independently ofwhatever task is being commanded by the robot programmer or operator.Moreover, the method does not require a robot to slow down or stop whena person (or other object) approaches. Rather, as long as the robot isaware of a person's dynamic position, the robotic arm may becontinuously adjusted to avoid collision.

As seen in FIG. 10, an origin of the arm angle plane is first determinedby finding the joint positions of the robotic arm in space, and thenfinding an angle between the vectors

and

This angle can be determined according to:

$\theta_{{J24},{J26}} = {\cos^{- 1}\frac{\overset{\longrightarrow}{P_{J2}P_{J6}*}\overset{\longrightarrow}{P_{J2}P_{{J4},R}}}{{\overset{\longrightarrow}{P_{J2}P_{J6}}}*{\overset{\longrightarrow}{P_{J2}P_{{J4},R}}}}}$

The origin position of the arm angle plane in space can then bedetermined according to:

${O_{PSI} = x_{0}},y_{0},{z_{0} = {P_{J2} + ( {\frac{\overset{\longrightarrow}{P_{J2}O_{PSI}}}{\overset{\longrightarrow}{P_{J2}P_{J6}}}*\overset{arrow}{P_{J⁢2}⁢P_{J⁢6}}} )}}$

where

${\overset{\longrightarrow}{P_{J2}O_{PSI}}} = \frac{1}{2}$

where because the distance between joints J2 and J4 is equal to thedistance between joints J4 and J6, and

$\overset{\longrightarrow}{O_{PSI}P_{J2}} = {\frac{- 1}{\overset{\longrightarrow}{P_{J2}P_{J6}}}*{\overset{arrow}{P_{J⁢2}⁢P_{J⁢6}}.}}$

Next, a collision sphere is created having a radius equal toD_(arm)+D_(buff), where D_(arm) is determined by solving the righttriangle generated between joint J4, joint J2, and the arm angle origin.That is, D_(arm) can be determined according to:

$D_{arm} = {\sin\theta_{{J24},{J26}}*{\overset{\longrightarrow}{P_{J2}P_{{J4},R}}}}$

Whether a collision point is within the collision sphere can bedetermined by comparing the distance from the origin to each point toavoid in World 1 to the radius of the collision sphere. Points notwithin the collision sphere can be discarded, while points within thecollision sphere can be projected on the plane defined by theintersection of

with the arm angle origin (the movement of the robot elbow beingrestricted to this plane) to create an image of each point on the plane.

The projection of the collision points within the collision sphere canbe accomplished according to the following algorithm:

a.

=

A,B,C

b. Plane EQ: Ax+By+Cz=Ax₀+By₀+Cz₀

c. Image on plane will be the point I_(n)=(α, β, γ)

d. Given a point in space denoted by (x, y, z), a vector can be definedthat is orthogonal to the arm angle plane and leads to the given pointin space, denoted as:

x−α,y−β,z−γ

e. The vector of d. will be parallel and proportional to

such that t*

=

x−α,y−β,z−γ

f. Therefore:

t*A,t*B,t*C=x−α,y−β,z−γ  i.

t*A=x−α→α=x−(t*A)  ii.

t*B=y−β→β=y−(t*B)  iii.

t*C=z−γ→γ=z−(t*C)  iv.

g. Given the above information known about the plane vector, originlocation, and the given point in space, the value of t can be solved forby plugging the image into the plane equation:

A(x−(t*A))+B(y−(t*B))+C(z−(t*C))=Ax ₀ +By ₀ +Cz ₀  i.

−1(A ² +B ² +C ²)t=A(x ₀ −x)+B(y ₀ −y)+C(z ₀ −z)  ii.

$\begin{matrix}{t = \frac{{A( {x_{0} - x} )} + {B( {y_{0} - y} )} + {C( {z_{0} - z} )}}{A^{2} + B^{2} + C^{2}}} & {{iii}.}\end{matrix}$

h. Once t is determined, it is possible to back solve for I_(n)=(α, β,γ) by plugging t into the equation derived in 3.e.ii-iv.

i. Repeat for each point within the collision sphere.

Once the collision points are determined and projected, an arm angle canbe calculated. The arm angle is defined as the angle between

and

. Both of these vectors lie on the arm angle plane, where the origin ofthe arm angle is

. However, because the calculation of the angle between these twovectors returns the absolute value of the angle, the appropriatequadrant of the angle is determined in subsequent steps. To determinethe quadrant of the arm angle plane that the image is in, a second planeis created containing

,

and O_(PSI). The image of each point I_(n) is again found on this newplane. In doing so, only the value of t needs to be determined, and thesign of the ratio value of t is determined as sign of the arm angle.

The arm angle values and the magnitude of vector

x−α, y−β, z−γ

are then used to determine a desired change in arm angle (reactiondelta) that is used to calculate the arm angle reaction due to thecollision point. The reaction delta follows the general linear formulaΔ=−m*|x|+b, with negative values filtered out. The value m is a constantthat determines how far away from the collision point the robot willreact, the value x is the distance between the current arm angle and thearm angle mapping of the collision point, and the value b is an offsetthat controls the magnitude of the reaction. B may be defined as

${b = \frac{D_{\max} + P_{\min}}{Z_{augmented}}},$

where D_(max) is a maximum desired reaction, P_(min) is a diameter ofthe robot joint if modeled as a sphere (accounting for the fact that thecollision point cannot be inside the robot), and Z_(augmented) is anaugmented distance from joint J4 to the collision point. The augmenteddistance reduces the effect of distance on avoidance as the point fallsaway from the reference plane. Due to the restriction of joint J4 to thereference plane, it is less important to avoid points that are far awayfrom this plane. The distance is calculated in the coordinate system ofthe reference plane and is determined as Z_(augmented)=√{square rootover (x²+y²+(Az²−Bz).)} Here A and B can be chosen based onrobot-specific dimensions. In one example, A=0.005 and B=0.05.

The delta that is calculated can be added to the current arm angle toproduce a new arm angle that is converted into a joint J3 velocity. Amaximum acceleration of a new delta may be capped to create atrapezoidal velocity profile to smooth acceleration. This further helpsprevent Cartesian position drifting when the direction of arm angleavoidance rapidly changes. With reference to FIG. 11, an appropriatevelocity function is determined for each of the arm angle positionsdetermined by the avoidance functions. The three velocities are thensummed to calculate a single optimal velocity for the redundant axis todrive avoidance of all hazards. The robot can then be controlledaccording to this optimal velocity.

The above-described 7-DOF control is not only applicable to a singlerobot in a clinical setting; rather, it can be applied to any number ofrobots working in a collaborative space. This method can optimize thepose of each of the robots for internal considerations (joint limits andsingularities) and external considerations (preventing itself fromrunning into neighboring structures, robots, or people). Further, theabove method can be used in any setting, including clinical surgicalrobotic settings and industrial manufacturing settings.

It is also noted that in some embodiments, the 7-DOF control may beproduced by a trained machine learning system. For example, such asystem may be trained to output relevant collision (or other avoidance)points (including anatomical regions to avoid), new arm angles, jointpositions, velocities, and accelerations based on input current armpositions and references, object positions and references, and the like.

Another aspect of the present disclosure relates to the coordination ofmovements of multiple robots. Referring back to FIG. 1, the coordinationmay be performed through a coordinator-dependent framework, where thecoordinator controller 102 is responsible for exchanging informationwith any number of dependent controllers 104, each locally controlling arobot 106. The dependents 104 rely on the coordinator 102 to commandactions, send and request information, and provide continuous data forexecuting tasks. The coordinator 102 relies on the dependents 104 torespond to commands, send requested information, and provide continuousdata required for the coordinator to manage activity execution andsynchronization appropriately.

With this framework, the surgeon 110 can manage a surgical procedure ofcoordinated tasks through the HMI 112, which displays a procedureflowchart and like information, patient models, images/videos of thesurgical procedure, patient vital signs, and the like, and receivesinputs adjusting the flow and execution thereof. In other words, the HMI112 can serve as a translator, communicating to the coordinator 102 theactivity that is to be executed. The coordinator 102 then coordinatesthe execution of that action, communicating commands to the dependents104 and in turn to the robots 106.

By way of more specific example, the coordinator-dependent framework canassist with safety monitoring by individual dependents 104 communicatingtheir health information to the coordinator 102, so that the coordinator102 can manage the totality of information and command appropriateresponses from the dependents 104. Additionally, the coordinator 102 cancommunicate the health status of the dependents 104 to the group so thateach dependent 104 can execute its own safety monitoring that isdependent on the group's health. Local safety monitoring may be handledby the individual dependents 104. This safety is driven by the limitsset in individual activities. These limits can be assigned by thecoordinator 102 but handled by the individual dependents 104.Additionally, the coordinator-dependent framework can assist withcollision avoidance between the robots 106 themselves, and betweenrobots and other objects in a setting (e.g., an operating room).Individual dependents 104 can stream their own collision point data tothe coordinator 102, which can then aggregate the collision data andcommunicate the collective collision data to the group so that eachdependent 104 can execute its own collision avoidance that is dependenton the pose of all robots 106. Additionally, the coordinator 102 canmanage static collision points and publishes them to network sharedvariables, accessible to all dependents 104.

The transfer of information and signals between elements of the system100 enables synchronization of multiple robots 106 performing theabove-described coordinated tasks, cohesive safety monitoring system,collision avoidance, and the transfer of data. Further, through thetransfer of information between the elements of the system thecoordinator 102 can manage selective time synchronization for any numberof dependent robots 106 all performing coordinated tasks. In addition,the above framework supports a methodology for robot movement that canbe paused or aborted based on real time data from any robot 106 in thatgroup.

In describing synchronization between robots 106, and with reference toFIG. 12, it is understood that a surgical procedure is a collection ofactivities and decision points therebetween. Each ‘activity’ is asurgical task (e.g., suturing) that is executed by one or more robots106 synchronized through subtasks (e.g., grabbing the needle) referredto as surgemes. Transition surgemes may be generated in real time toconnect one surgeme to another. Each surgeme is a collection of‘dexemes’, which are sets of paths, trajectories, or other parametersgiven that cause an intended motion to be completed by an actuator. Eachdexeme involves only one robot 106.

When performing automated tasks, a dexeme can be considered as atrajectory encompassing a series of setpoints in time (or alternativelya series of setpoints to be scheduled based on prescribed rates) wherethe desired motions and loads of the robot instrument can be explicitlydefined. Any specific surgeme can include any number of dexemes, and thegrouping of a collection of dexemes into a single surgeme is definedthrough synchronization groups.

Synchronization groups include specified dexemes that make up a surgemethat all follow specified synchronization parameters. In someembodiments, multiple synchronization groups can be created such thatnot all robots 106 are required to be synchronized for all activities.The synchronization parameters include a synchronized start, asynchronized end, and a synchronized clock. If dexemes start at the sametime, then they have a synchronous start. Once a robot 106 is ready tobegin their dexeme, they signal that they are ready to the coordinator102. Once all robots within the surgeme have signaled that they areready, a start command from the coordinator 102 may be sent at the sametime to each robot 106 through their corresponding dependents 104 toensure the synchronous start. In addition to waiting for included robots106 to be available, a synchronization group might also rely on thecompletion of another synchronization group in order to start. Forexample, if robots 3 and 4 are executing a task that must be completedfirst or they are in an area that must be cleared before starting asurgeme involving robots 1 and 2, then robots 1 and 2 wait until thesurgeme that robots 3 and 4 are executing is completed.

Similarly, in some cases dexemes within a surgeme should be terminatedwhenever any dexeme in that surgeme ends, even if prematurely. Suchpremature completion can be due to safety, but also could be because atermination criteria has been met. For example, a dexeme can end when adesired load on an actuator is met; and if a synchronized end parameteris set for the surgeme, the completion of that dexeme will result in thecompletion of all dexemes within that surgeme. A natural end may also besynchronize. For example, a retracting dexeme can be set to terminatewhen a cutting, excising, or reconstructing dexeme is completed, andthus retraction is no longer needed.

In order to ensure such synchronization of dexemes, a master clock(e.g., belonging to the coordinator 102) can be used in lieu of localclocks belonging to each robot 106 or corresponding dependent 104. Inthese cases, time is multicast to all robots 106 in the surgeme from thecoordinator 102 or other location of the master clock. By using a commonclock, it is possible to pause multiple dexemes if one dexeme is paused,and/or to adaptively modify times across multiple dexemes.

FIG. 13 illustrates how dexemes, surgemes and activities fit into anexample planned procedure. Therein, a series of dexemes and surgemes areshown for two activities, executed by four robots R1-R4. In Activity 1,each of the robots R1-R4 are grouped to perform a first surgeme having asynchronous end. Robots R2 and R3 then perform a surgeme having asynchronous beginning and end, while the second surgeme of robots R1 andR4 has a synchronous start but an asynchronous end. When the seconddexeme of robot R4 is finished, robot R4 waits for the second dexeme ofrobot R1 to finish prior to a synchronous start for the third surgeme ofrobots R1 and R4. Activity 1 ends upon the completion of the thirdsurgeme of robots R1 and R4.

Following Activity 1, the procedure waits for any transition conditionsto be met at the Decision Point prior to beginning Activity 2. Robots R1and R2 then jointly execute two surgemes, each having a synchronousstart but asynchronous end. Similarly, the first two surgemes jointlyexecuted by robots R3 and R4 have a synchronous start but asynchronousend. However, the third surgeme jointly executed by robots R3 and R4have an asynchronous start, but a synchronous end.

During the procedure, a local safety monitoring process occursindividually for each activity. Meanwhile, a global safety monitoringprocess occurs over the entirety of the procedure.

The coordinator-dependent framework can rely on one or more of thefollowing streams of information between the elements of the system 100.In a coordinator-dependent command stream, bidirectional information isonly exchanged when the coordinator 102 sends or requests it. Thecoordinator 102 can request information (e.g., data files, trajectorysets, dexemes, adaptive compensators, and the like), send information(e.g., trajectory sets and dexemes, adaptive compensators, and thelike), and send commands (e.g., prepare, run, pause, abort, skip, andthe like). In a dependent health and status stream, unidirectionalinformation is continuously streamed from each dependent 104 to thecoordinator 102 at a set frequency. Information in the dependent healthand status stream may include a health status of the dependent 104 andcorresponding robot 106, dynamic collision points, and a trajectoryexecution status (e.g., running, waiting, preparing, aborting, skippingto next, paused, and the like). The data of the dependent health andstatus stream may be used by the coordinator 102 to help manage tasksynchronization and monitor safety. In a coordinator global data stream,unidirectional information is continuously multicast from thecoordinator 102 to all dependents 104 at a set frequency. The data ofthe coordinator global data stream can include global sensor data (e.g.,multiple dependents rely on the same sensor data), global health data(e.g., function of local health of each dependent and informs alldependents on the overall health of the system for safety monitoring),aggregated dynamic collision points (e.g., compilation of dynamiccollision points for all dependent), and time (e.g., from global clockto ensure synchronization). Depending on the frequency, coordinatorglobal data information can be output in a single stream or multiplestreams. A dependent robot stream transmits control signals from thedependent 104 to the robot 106 for execution specific movements, andreceives sensor information from the robot (e.g., position information,instrument information such as an applied force and/or position).Further, static data that should be accessible by the coordinator 102and dependents 104 can be saved as a network shared variable, hosted onthe coordinator 102. Such information can include static collisionpoints and static registration parameters, and may be readable andwriteable by the coordinator 102 and dependents 104.

A coordinator interface data stream communications data from thecoordinator 102 to the HMI 112, for monitoring by medical personnel 110.Information of the coordinator interface data stream can includedependent status and health, model data, and other specific informationthat the HMI utilizes to run the user interface. Similarly, an HMI usersensor data stream communicates data from the HMI 112 to the coordinator102, including any data for continuously updating the rest of thesystem, such as data from hardware and sensors connected to the HMI.Finally, an HMI coordinator command stream is a transactionalcommunication between the HMI 112 and coordinator 102. These commandsrelate to the execution of a procedure, for example, including a nextactivity to execute, or specific controls for the robots 106.

The coordinator 102 can request data from the dependents 104 allowingfor a complete compilation of data. All of the available data may beaccessed by medical personnel 110 via the HMI 112. With thisinformation, and the ability to send commands to the coordinator to inturn control each of the robots 106, the medical personnel 110 caninteract with, control, and monitor the surgical system 100. Another jobof the coordinator 102 is to manage the above-described synchronizationbetween robots 106. The HMI 112 can send an activity to be executed tothe coordinator 102. The coordinator 102 may then unpack the activity,and analyze the surgemes and dexemes therein. Based on the surgemes anddexemes associated with the activity, the coordinator generatestrajectory (or like motion control) information (a trajectory plan) foreach dependent 104 and associated robot 106. These trajectories andother movement data may be based on the above-described methods foroptimization, collision avoidance, interaction with deformable objects,and the like. Commands for executed the movements are then sent from thecoordinator 102 to the dependents 104 so that each dependent 104 andcorresponding robot 106 can perform the associated dexemes for thatactivity in the appropriate synchronization/order. The coordinator 102can also send any pause, stop, or abort commands to each dependent 104.

Another feature of the coordinator 102 is to manage the global safetymonitoring system. The safety monitoring system detects any unscheduledevents or actions by the dependents 104 or robots 106, and stops thesystem 100 from causing harm if such events or activities are detected.In one example, potentially harmful events or actions can be detected bymonitoring sensor inputs and comparing them to expected values based onthe current activity being executed. The global system may alsoprescribe and communicate robot-specific safety parameters to eachdependent 104 for individual local safety monitoring.

The dependents 104 take the information communicated by the coordinator102 and transform them into control signals that drive theircorresponding robot 106. During each activity, the dependent 104acquires a trajectory set of dexemes from the coordinator 104 and thenwaits for the coordinator's commands regarding what to do with thedexemes in the trajectory set sequence. Additionally, the dependent 104receives collision avoidance data from the coordinator 102. This datacan include all coordinates of objects (e.g., of other robots, ofobjects in the surgical room, anatomical areas, and the like) to beavoided by any portion of the system 100. This avoidance information canbe used to drive the redundant joint of the robot to avoid a collision,as described above. This process of taking the trajectory sets andturning them into commands and robot movements is described in U.S.patent application Ser. Nos. 17/157,237 and 17/157,693, which areincorporated herein by reference in their entireties. The dependents 104also perform local safety monitoring based on the robot-specificparameters received from the coordinator 102.

The above-noted HMI 112 can have multiple uses within the system 100. Inone example, the HMI may provide an interface for medical personnel 110to interact with and control the system 100. For example, such controlmay be based on a user-generated flowchart of a surgical procedure. Themedical personnel 110 can interact with the HMI in any manner including,for example, through a touch screen or other monitor, keyboard, mouse,joystick, foot pedal, camera, throttle, eye-tracking, microphones,speakers, VR headsets, monitors, and the like. These inputs are thencommunicated to the coordinator 104 in the manners discussed above.

The procedure flowchart describes how a surgical procedure is to beexecuted by the robots 106 of the system 100, and can originate frompreplanning as described in more detail below. As suggested in FIG. 13,the flowchart comprises two types of elements: activities and decisionpoints. Activities are surgical actions that are executed by one or moresurgical robots 106. Decision points act as branching points where testsor user input help choose the proper action to move forward. In otherwords, a decision point determines to which of two or more subsequentactivities a surgical procedure should advance to. When the nextactivity is identified at the decision point, the decision is sent tothe coordinator 102, which coordinates execution of that activity.Global sensor data, system health, and dependent dexeme status datacommunicated from the coordinator 102 to the HMI 112 help medicalpersonnel 110 determine status and navigate through the flowchart. Insome embodiments, the flow chart may be maintained at the coordinator102, which automatically makes decisions at each decision point based onthe available data to automate execution of the surgical procedure.

Prior to each procedure, a user can choose settings and configure thesystem 100 for a specific patient's procedure through the HMI 112. Inone example, the user can import any or all necessary data for executinga customized procedure including, for example, simulation data regardingthe patient's anatomy, setup, and equipment used to create theprocedure. During this setup, the HMI 112 may also inform usersequipment placement, sensor initializations, patient orientation,registration of robots and instruments, and the like. In someembodiments, setting up the operating room can be illustrated on the HMI112 in a mixed reality interface where a simulated scene from theimported data displays a phantom overlay with reality. In someembodiments, the arrangement of elements may be displayed on a floorplan or like 3D model of the operating room. After setup, the HMI 112may guide verification of connectivity in the equipment, any patientinformation, and any safety criteria.

The HMI 112 may also display a comprehensive virtual patient model thatmimics the current state of the patient's tissues. These models may beregistered to actual sensors on the patient during the surgery, asdiscussed above, such that the models are adjustable in real time tomimic the state of the biological tissue during the procedure. Themodels may be updated, for example, based on space warping method tomimic the defamation in the tissues. Another model can monitor a jointcoordinate system and compare it to a world instrument position to focuson the adjusting model's local area compared to the instrument position.This approach can prioritize modifying the model area closer to thenearest tool to preserve computational power. Another method can usemultiple cameras in real time to compare the biological tissues with themodel. This method can find any discrepancies between the model andtissues to update the model or notify the user of differences. Thevirtual patient models may also be displayed on a screen, or as amixture of virtual reality and physical reality. The mixed reality canallow for rendered virtual models to be overlaid onto a camera feed tohighlight anatomical features. For example, predefined avoidance regionswithin the anatomy may be displayed via the HMI 112 (e.g., overlaid onreal time intraoperative images or an anatomical model) to the medicalpersonnel as a visual reminder of anatomical features to avoid.

In some embodiments, the avoidance region may be shown in a first visualmanner (such as with hatch marks, stippling, in a red color, or thelike) that is different than a second visual manner showing anacceptable operable region (e.g., in green or uncolored). Still furthera third visual manner may be used to denote additional information. Forexample, a trajectory or like surgical path, cut margin, or the like maybe illustrated as the second visual manner (since it may be consideredacceptable), or in a third visual manner such as a line (dashed, black,or the like). Using a third visual manner can help make the additionalinformation more visible within the acceptable region.

An activity's ideal surgical path could also appear in a mixed realityscene when the system is in teleoperated, as a guide for the medicalpersonnel 110. The path may also include directional information,illustrated by arrows along the path. If the system 100 is in acollaborative or autonomous mode, then the planned course appears, sothe medical personnel knows where each robot intends to move. Similarly,cut or excision margins may be shown when tissue or tumors are excisedor cut.

In some embodiments, the HMI 112 may also record a procedure, includingthe data and commands of the various controllers of the system 100,video of medical personnel, trajectory information of the robots 106,displays of the HMI 112, procedure flows, and the like. Such informationcan be maintained for records, for playback to review the surgery,and/or training of medical personnel 110 and/or the above-describedmachine learning systems. Further, these recordings may be timestampedand include voice or other notes associated with the time stamps.

Similarly, the HMI 112 can display analysis reports of a surgicalflowchart's execution and give the user statistics regarding theoutcome. Such statistics may relate to a length of surgery, amount oftime cutting, the total length of cuts, and the like. Cost (financialcost of materials, total time, and the like) can also be analyzed toprovide an efficiency score of the procedure. Accuracy and error can bedetermined based on comparison to pre-operative simulations to identifyhow accurate the execution of the procedure was. Such outputs canfurther be used to train new surgeons or improve experienced surgeons'skills.

Joysticks of the HMI 112 may be configured for auto-clutching, such thatthe clutch repositions the joystick without moving the robots 106 toadjust for physical limitations in human joints and workspace limits.Accordingly, the system 100 may recognize when joint space and humanlimits are reached and adapt to the operational field. When the userexceeds limits and holds the joystick position, the controlled robot 106can continue to move in a low-speed velocity mode. This control featurecan effectively adjust the field of operation of the joystick. In thismanner, the robot 106 does not have to stop moving to be changed andspeed up a procedure.

The HMI 112 may also provide a “snapping” effect where a user's controls“snap” to a determined position as it is approached. Such a controlallows a user to increase precision in their controls by, for example,predefining a snapping point. Such controls can be applied to robotmovements, camera positions, or any other objects controlled by the HMI112. Once the “snapped” position is reached, further micro adjustmentsmay be made by the user. More particularly, a user may control rates ofexecution of movement. Providing a slower rate allows more precisecontrol such that the micro adjustments may be made.

In some embodiments, a user may guide autonomous movements of objects,such as the robots 106. For example, a user may select individualbuttons that correspond to activities, surgemes, dexemes, or the like,in a surgical flowchart. In other words, a user effectuate the start ofan action or series of actions by a robot 106 that are automaticallycontrolled by the system 100 once started. For example, if additionalbleeding occurs, the user may press a button that applies additionalsuction to the workspace. In another example, a user may press a buttonindicating the decision made at a decision point.

Cameras of the HMI 112 may be stereoscopic camera feeds that generate 3Dvideo to render a 3D virtual scene. 3D rendered objects and models canbe displayable over top of the stereoscopic camera feed. 3D scenes maybe displayed on 2D monitors, VR headsets, and the like. Various controldevices, such as the joysticks, may have six degrees of freedom togenerate the proper commands to control the robots 106. The controldevices may also have haptic feedback to alert the user of movements ofthe robot 106, of interaction between the robot instrument and thepatient's tissues, and the like. Given the patient's known anatomy, itis possible to give accurate haptic feedback data based on the tissue'smechanical properties.

Another aspect of the present disclosure relates to a pre-operativeplatform for planning, refining, and generating a sequence(s) of robotmovements for autonomous or robot-assisted surgical. Such a platformfollows, for example, the procedure illustrated in FIG. 14. As showntherein, the process includes first rendering conditions of theprocedure, then recording a sequence of a predefined movements andconfiguring the surgical robotic system, rehearsing the procedurevirtually, refining the procedure to increase efficiency and eliminateunnecessary movements, and finally reporting a finalized procedure forin vivo execution.

In one example, rendering can involve generating an in silico scene tomimic the conditions present during a specific patient's procedure.Rendering may be of the operating environment and/or the patient.

The scene rendering of an operating environment may be performed by oneor computers in which a user (such as the medical personnel or surgeon)can drag, drop, and move objects in a virtual space commonly seen in asurgical operating environment to mimic the operating room that theindividual patient will use. The objects may be dynamic (e.g., thosethat can move, change shape, and displace via dynamic meshes and joints,such as robots, cameras, end effectors, instruments, and the like) orstatic (e.g., rigid bodies that do not move such as tables, cabinetry,carts, workstations, and the like). Render the environment allows foraccurate spatial representations and relationships of the objects andtheir positions in the workspace for movement planning considerations(e.g., robotic collision avoidance). The rendered scene can be viewablefor example via a 2D screen or through a virtual reality device.

Once rendered, the scene may be optimized to suggest an ideal workspacearrangement. Such a workspace allows for the greatest field of motioninside the patient, minimizes the chance of collision between objectsduring the procedure, and provides the greatest freedom for the roboticlinkages used in the procedure to avoid joint limits or singularities.

Rendering of the patient may include an anatomically correct 3Drepresentation of the patient and any tissues being operated on. Theserenderings may be based on sensor or imaging (e.g., CT and/or MRI) datafrom the patient. Further, different physical properties may be appliedto the various types of tissues to mimic their real-world interactionwith objects, such as the instruments utilized during the procedure.These physical properties thus can include mechanical properties orvisual properties of the tissue. Anatomical features outside a region ofinterest (e.g., the region the procedure is performed on) may begeneralized with a prefabricated model that is scaled to be proportionalto the patient's height and weight in order to preserve computationalpower during the simulation.

Recording the procedure may involve generating a sequence of predefinedmovements and configuring the surgical robotic system accordingly. Tofacilitate the quick and efficient creation of procedures, the frameworkcan be configured to import templates of common procedures, activities,surgemes, dexemes, and/or motion profiles of individual robots. Thesetemplates may have been previously optimized, deemed safe, and/orotherwise evaluated as acceptable. Additionally, a user can create newprocedures, activities, surgemes, and dexemes by defining specificindividual motions of the robot or by arranging the above-notedtemplates.

New motions may be defined by, for example, using motion tracking totrack a surgeon's tools as they perform a task or to record ateleoperated robotic surgical instrument as a surgeon performs a task;recording a surgical instrument's or robot's reported cartesianpositioning to create a motion profile while executing a teleoperatedsurgical task or recording a surgical instrument's or robot's jointpositioning to make a motion profile while performing a teleoperatedsurgical task; recording forces exerted during a teleoperate roboticsurgical task or during a surgical task executed by hand; and/orrecording deformation of the anatomy during surgical task execution orutilizing sensor fusion to determine and record the state of the anatomyduring the performance of a surgical task.

The above tracking and recording can be from surgical tasks performed onprevious patients, cadaveric specimens, animal subjects, 3D printedanatomical models, and the like. Further the data collected from theabove tracking and recording may be from force, vision, motion,electromagnetic, radioactive, biometric impedance, temperature, and likesensors. The system may then translate this data associated with eachtracking and recording (e.g., gain profiles, kinetics, positions, andthe like) into individual motion profiles. Each profile may be thencollected into a dexeme, surgeme, activity, and/or procedure. This datamay also be utilized to generate or evaluate decision points and/or forlocal/global safety monitoring criteria.

A procedure editor allows the user to create, edit, and otherwiseorganize the individual movements, dexemes, surgemes, activities anddecision points into the procedures. Each of these elements may bedisplayed to the user in the form of one or more flow charts, in whicheach element can be arranged by a “drag and drop” style user interface.Each element can also be selected and expanded to give more specificinformation. For example, one flow chart may illustrate a procedure as aseries of activities and decision points. A user may then select andexpand an individual activity on the procedure flow chart to displaythat activity as a series of surgemes. Similarly, selecting andexpanding each surgeme may further display the flow of the individualdexemes therein, and selecting and expanding each dexeme may display theindividual series of motion profiles therein.

Example flowcharts of the procedure editor are illustrated in FIGS. 15Aand 15B. Both FIGS. 15A and 15B illustrate a procedure that includesclamping an artery. FIG. 15A first illustrates a non-decision basedversion of the procedure, which the procedure advances through a seriesof activities linearly. As seen therein, the procedure begins with theactivity of opening the patient, and then proceeds to the activity ofgrabbing a clamp. With the robot holding the clamp, the procedurelocates the artery to be clamped and then performs the clampingactivity. Once the artery is clamped, the procedure can proceed to anyadditional activities.

FIG. 15B illustrates the same procedural flow but with decision pointsbetween actions. Of note, the linear path of FIG. 15A generally remainsin the middle of the flowchart in FIG. 15B. However, a first decisionpoint between the act of opening the patient and grabbing the clamp isbased on whether a proper field of view (FOV) has been acquired. Inother words, is the incision large enough to provide proper access forthe remainder of the procedure? Here, the decision is based on a userinput. For example, a medical personnel 110 may be prompted on an HMI112 to identify whether FOV is appropriate via a pop-up window withbuttons representing “yes” and “no”. Depending on the decision, furtherinput may be requested. For example, in the event the FOV is notappropriate, the decision may also request the user to input via the HMI112 (e.g., with a controller, or drawing on a visual representation ofthe incision site) a desired incision path to achieve an appropriateFOV. The incision may then be extended, and the decision represented. Inother embodiments, the decision may be automated based on image analysisof the incision. Once the appropriate FOV has been determined, theprocedure proceeds to grabbing the clamp. If sensors determine (e.g.,based on locations of the clamp by position sensors or image analysis,appropriate forces are detected, or the like) that the glamp was notsuccessfully grabbed, the clamp is released and the user is presentedwith another decision of whether to control the robot tele operatively.That is, the user is presented with the option of taking control of therobots manually to perform the clamp grab. If the user elects tomanually control the robot(s), the procedure flow may be re-entered atany location.

If it is determined that the clamp is successfully grabbed, the arteryis located and then clamped according to those activity definitions. Ifsensors or a user then determine bleeding in the patient (thusindicating a poor clamp), the clamp is released. If it is determinedthat the bleeding has stopped, the procedure can again locate the arteryand attempt to re-clamp the artery. If the bleed has not been stopped,suction is applied to the bleed and the user is asked whether they wishto teleoperatively control the robots to stop the bleeding. Once theartery is clamped and no bleed is detected, the procedure can thencontinue.

As noted above, each action and decision point and the connectionstherebetween may be adjusted pre-operatively or in real time by aflowchart editor. This may be accomplished in one embodiment by simply“dragging and dropping” each element of the flowchart based on definedactivities and decision points. Should a user wish to modify theactivity definitions, each activity may have a flowchart similar to thatof FIGS. 15A and 15B (with the corresponding surgemes and dexemes), orcharts similar to those illustrated in FIGS. 12 and 13. Again, howevervisually presented to a user, the elements (activities, surgemes,dexemes, motion profiles) can be modified visually to adjust the actionsperformed by the robots. While editing, the system may be configured toanalyze the procedure in real time to identify any potential errors orimproper combinations of activities and decision points. For example, itwould not be appropriate to clamp an artery without first identifyingthe artery or grabbing the clamp. In the event an impropriety isdetected, the editor may suggest or automatically change the procedure.Users may also provide comments to the flowchart for later review anddiscussion.

Similar to identifying improper activities, the above-discussed safetymonitoring system may be configured to sense and manage unscheduledevents based on the procedure flowchart. Even though the procedureflowchart's decision-based architecture can handle contingencies, it isnot guaranteed to cover every possible scenario in surgery. A safetymonitoring system can thus analyze the procedure based on a givenflowchart and monitor any unscheduled events, such as additionalbleeding, increase/decreased blood pressure, increased/decreased heartrate, unexpected oxygen saturation changes, instrument malfunctions,excess forces, unexpected visual properties, or unexpected anatomy. Thismonitoring system can employ multiple levels of control. At the highestlevel of control, the system can have the ability to override anautomated procedure. Lower levels of control may simply display or sounda warning when criteria are triggered, or give the medical personnel theability to change into a fully teleoperated control mode. The levels ofcontrol may be separately defined for each event. These criteria canhelp determine whether to continue, come to a controlled stop, or cometo an emergency stop. Additionally, the safety monitoring system canapply an adaptive compensation to dexemes to adjust the trajectory andmotion profile of a robot in real time to adapt to any potential ordetected events.

The global safety monitoring system may be set to run continuouslyduring the simulation or execution of the procedure, spanning multipleactivities. This level can monitor the highest levels of motion, such astracking the occurrence of an unscheduled event. The criteria of theglobal system may not change through the course of the procedure. Incontrast, the local safety monitoring system applies to execution eachactivity, surgeme, and/or dexeme individually. The criteria monitored bythe local safety system can be directed to activity-specific ormovement-specific issues that may occur, such as making sure a specificforce profile is not exceeded during a cut, excision, or reconstruction.

These criteria (and resulting actions) for each safety system may bedetermined and set during the procedure planning based on pastprocedures and activities, or manually input by a user. For example, theuser can identify a sensor state associated with a fault (e.g., a forcethreshold, positional limit, and the like). Further, terminationcriteria can be determined for each fault, or for multiple levels offault. For example, a user may define that for a first threshold offorce detected, the medical personnel are simply presented with awarning or option to take teleoperative control; for second higherthreshold of force detected, a controlled stop is initiated; and for athird even high threshold force detected, an emergency stop is appliedto the system. In other example, a similar progression of warning,controlled stop, and emergency stop may be applied if robot movementvelocities or accelerations increase above defined thresholds, or ifrobot or instrument positions approach or enter avoidance regions(either in the operating environment by the robot, or an anatomicalregion by the instrument). To further ensure safety, medical personnelmay always have the ability to enable manual control of an automatedrobot actuator.

Once the procedure has been created, it may be simulated in a virtual orphysical setting. Virtual simulations may include a 3D virtualvisualization of the procedure so that the user can view the procedurein time via video manipulation tools like play, pause, fast forward,rewind, and the like. Additionally, the user can interact with theflowchart to jump to different sections of the simulation. This systemcan simulate both the physical state of the robot and the physical andphysiological state of a patient at any given time. The simulationdescribed here can be produced to be viewable via a 2D screen or througha virtual reality device. The physical simulation may be performed on aphysical specimen (e.g., cadaveric specimens, animal subjects, 3Dprinted anatomical models) on which an automated robotic surgical systemcan execute the procedure.

Based on the simulations, the procedure may be refined (e.g., optimized)to increase efficiency and eliminate unnecessary movements. Thisoptimization may be performed at least in part as earlier-describedbased on machine learning as applied to any level of the procedure(e.g., activities, surgemes, dexemes, and movementprofiles/trajectories). In some embodiments, the unnecessary movementsmay alternatively or additionally be identified by tracking thesimulation. The optimization may be performed during the simulation orafter. For example, if an unnecessary movement, activity, or the like isidentified during the simulation, the user may pause the simulation toremove the unnecessary action, and then resume (or repeat) theprocedure. Optimization can also take the form of determining how topair subsequent dexemes, surgemes, or activities to create new actionsthat a robot, but not a human operator, can execute.

Finally, a report of the (optimized) procedure may be output for finalreview by a user. Similar to the reports described above with respect toa medical personnel's performance during a surgical procedure, thisreport may provide an analysis of the simulation outcome or predictedoutcome (if no simulation is performed). Such statistics may relate to alength of surgery, amount of time cutting, the total length of cuts, andthe like. Cost (financial cost of materials, total time, and the like)can also be analyzed to provide an efficiency score of the procedure.Accuracy and error can be determined based on comparison topre-operative simulations to identify how accurate the execution of theprocedure was. Such outputs can further be used to train new surgeons orimprove experienced surgeons' skills by evaluation. Further, the systemcan compile the flowchart into a series of control signals for eachassociated robot to generate an executable procedure in the form of aseries of trajectory plans for each robot. In other words, similar tohow source code may be compiled to form a software program executable bya computer, the procedure flowcharts may be compiled into a list ofcommands executable by dependents 104 and robots 106 that result in theexecution of the procedure via motion of the robot according to thedetermined trajectory plan.

The above planning framework and system architecture overcome currentlimitations of purely tele-operated systems, to become an autonomous orcollaborative system. The features herein facilitate a system that caninterpret and use real-time sensor data to execute a surgical procedurein which communication latency and security risks do not pose the samebarriers to the surgical as in teleoperations over large distances usingthe Internet or other preexisting communication networks. In otherwords, a system that is capable of being taught (through surgicalplanning) on virtual surrogates for patient specific anatomy can operateremotely and autonomously on that patient and utilize learned specificsurgical maneuvers for some or all of the surgery. With only thesupervision of a human surgeon, the pre-learned complex surgicalmaneuvers used throughout the surgery would not be susceptible tocommunication latency that might otherwise cause the robot to move in anundesirable way.

Further, the above-described pre-operative planning information,reports, procedure flowcharts, and executable procedures (having theappropriate commands for individual robots to execute the movements andtrajectories associated with a procedure, activity, surgeme, or dexeme),can be exported in varies data structures and formats. For example,exported files may be structured using JSON or XML, to allow the file tobe human readable and editable outside of the above-described editor.Such files may also be encrypted or otherwise secured for transmissionbetween different systems, or storage.

As suggested above, virtual models of a patient-specific anatomy may beutilized in various aspects of the present disclosure. For example,these models may be used to plan robotic procedures, as virtual sensorsfor predicting the patient's tissues in simulation or an actualprocedure, act as a blueprint for creating a 3D print of the anatomicalfeature with correct properties, and the like. These models may derivefrom medical imaging data collected for a given patient and be furtherdefined by characteristics (e.g., embodied as variable-driven formulas)such as deformation, elasticity, or cutting elements.

Achieving the proper scale and accuracy of the model can be achievedaccording to the example process of FIG. 16. Briefly, the processincludes collecting data from experiments, literature, imaging, and thelike to establish a baseline and particular characteristics of theanatomical tissue (e.g., ranges of appropriate values) from which, themodel can be derived. The model may then be generated and validated.Finally, the model may be used for preparation and analysis of thesurgical procedure, including for example, building an operating scene,estimating tissue function, and performing physical simulations.

More particularly the first steps involve data and image collection tounderstand the physical laws and characteristics that should govern the.In other words, this data may provide a baseline from which the virtualmodel can be derived from. This is because the human body has manytissues, each having their own set of properties that define how itreacts to external stimuli. For example, a kidney includes at least thefollowing types of tissues: medulla, cortex, artery, vein, ureter, andcollecting system. Each tissue may have different characteristics (e.g.,thickness, elasticity, strength, color, density, friction coefficients,changes due to cuts, deformation characteristics, and the like), whichfurther vary from patient to patient, and further can vary based on thetissue's and/or patient's orientation. Due to this, the initiallycollected data may be used to derive a range of values for each of a setof desired characteristic of the tissue, including in a plurality ofdirections for the orientations of interest. This data may be collectedexperimentally (including of the tissue itself and its interactions withvarious surgical instruments), literature studies, medical imaging, andthe like; and may represent the specific patient and/or a generalpopulation. Such data may include the forces needed to cause a tissue tochange shape in a given direction, represent how the material changesshape when a given force is applied, determine the resistance (e.g.,mechanical or electrical) of the tissue when cut in a given direction,determine a spring constant for each direction of the tissue, and/ordetermine how the tissue reacts when cut in a given direction.

Each characteristic of the tissue may be itself modeled as a function ofone or more variables. Using the noted elastic constant as an example,an elasticity characteristic may be modeled as f(k, x)=kx where f(k, x)represents an applied force over a distance x, and k is the elasticityconstant of the tissue. The collected data may be used to then identifya range of values for the elasticity constant k.

Once the desired characteristics (and their ranges) are determined, theymay be refined for example through wet and dry lab conducting moretargeted studies on the characteristics of the tissues. These studiesmay give a better representation of how the tissues react to toolscommonly used in a procedure. Iteratively refining the characteristicscan improve their accuracy.

The acquired medical images may include those from any modality, such asCT, MRI, ultrasound, and the like. Once acquired, the images may besegmented to identify different types of tissues in the imaged anatomy.The segmented images may then be saved and converted to model formats,such as STL, OBJ, STEP, and the like.

With the characteristics defined and the basic visual model shapesgenerated, the characteristics (and associated models) are applied tothe basic visual models, thereby giving the visual models physicalproperties and characteristics of the actual tissues. Using the kidneyexample from above, the medulla and cortex regions of an MR volume of akidney may be segmented out and separately converted/saved as 3D models.Because the MR volume is taken from the patient, the resulting 3D modelsthus match the patient-specific anatomy. Further, the elasticity andother characteristic models associated with each segmented region maythen be applied to those segmented models. Accordingly, when ultimatelyrecombined to form a full model of the kidney, the voxels associatedwith medulla may be treated as having an elasticity coefficientrepresentative of the patient's medulla, and the voxels of the cortexregion of the full kidney model may have a patient-specific cortexelasticity coefficient that is different than that of the medulla.Similarly, deformability characteristics, characteristics relating tohow the tissue interacts with various surgical instruments, and othercharacteristics of interest may be applied to each model.

Once model generation is completed, the model is validated and exactcharacteristic values may be determined. In one embodiment, validationoccurs with a network of sensors

The next step can utilize a network of sensors to validate the virtualmodel to set the variable's exact value for all formulas. For example,the sensors may measure an actual response of the tissue to a stimulus,and compare the actual response to the response output by the model. Ifthe model output is within a predetermined range of the actual response,the model may be considered verified.

The final model may then be used in manner, such as those describedabove. For example, the model can be used to build an operating roomscene, analyzed to estimate organ function due to a procedure, or buildphysical models for simulations. Additionally, a trained machinelearning system may be utilized to continually update the model (e.g.,in real time). For example, the machine learning system may be trainedto receive sensor data during a procedure, and adjust characteristics ofthe model according to any changes in received sensor data. Therefore,as the body is changing throughout the procedure, so can the virtualmodel.

As noted above, one element of the pre-operative planning process mayinclude generating an operating room scene. Each operating room scenemay be specific to a room, patient, and/or procedure. Thus, in someembodiments, each operating room scene may be generated from scratch.However, because many procedures may share commonalities (e.g., beperformed in the same room, with fixed structures), each operating roomscene may also be based on predefined templates.

When generating a new scene, a user may first start by defining afloorplan corresponding to the operating room. The dimensions of thefloorplan can include the wall lengths, corner angles, and wall heights.That is, the floor plan may be in two or three dimensions. Thisfloorplan acts as the ultimate boundaries that all objects must liewithin.

After the room boundaries are defined, the user can populate the roomwith operating room objects. These objects may have static positions,such as furniture (e.g., tables, cabinets, chairs), or dynamicpositions, such as people, devices and machines (e.g., robots,end-effectors) that are expected to move throughout a procedure. Eachmodel within the scene can have a predefined zone around it to preventcollisions. Each zone can be specific to the individual models andchanged by the user for each model's instance.

Each object populating the room may have its own 2D or 3D model, whichmay be predefined or generated specifically for the scene. Additionally,the element may be represented by a generic model or one with exactingdimensions to the actual element that will be in the operating room. Inaddition to having appropriate dimensions, models for dynamic objectsmay also have appropriate physical properties such as defined joints andmotion abilities. All models may be positioned relative to a roomorigin, such that all of the models are in a common coordinate systemand are scalable.

A populated operating room scene may then be input to a machine learningsystem trained to output an optimized scene or suggestions foroptimizing the scene. For example, the machine learning system mayrecognize that two robots of a user-defined scene are located in tooclose proximity with each other, thereby increasing the chances ofcollision and the need for inefficient collision avoidance movements.Accordingly, the machine learning system may output optimized locationsfor each robot that avoid such collision problems. Such a machinelearning system may also be trained with information relating tospecific procedures. For example, an orientation of multiple robotswithin an operating scene may be optimized for one procedure, butproblematic for another procedure. By considering the specific movementsof the robots associated with the procedure for which the operating roomscene is being designed, the machine learning system can generateprocedure- and room-specific scenes. This trained machine learningsystem (and/or the optimization generally) may be applied iteratively.For example, an initial scene may be generated and optimized and used ina simulation during a pre-operative planning (e.g., such as thosediscussed above) in which a movement error (e.g., singularity,positional error, joint limit, and the like) is recorded. That error maythen be input into the trained machine learning system to furtheroptimize the scene to remove the error. Similarly, and as discussedearlier, the machine learning system may be trained with past operationdata. Thus, the outputs of the machine learning system can also be basedon operating room scenes used in prior procedures, and their outcomes.

As noted above, each object in the operating room scene may be static ordynamic, and have defined zones to prevent collisions. For example, theuser can place two identical tables in a scene, each instance having adifferent zone based on the space where it is located. During aprocedure or simulation, when another object within the scene entersthis zone, a warning may be generated to communicate to the movingobjects that a collision is imminent. When the warning is triggered,appropriate actions may be taken such as repositioning the moving objectto exit the warning zone or slowing down the speed of the moving objectto minimize damage if a collision occurs.

Robot and end-effectors are specific dynamic models that have uniqueproperties. With reference to FIG. 17, a model's movement is categorizedwithin two types of zones—full range and functional workspace. The fullrange of a robot 1700 can be defined as every possible location 1702that the robot 1700 can move. The functional range 1704 is the areawithin the full-range 1702 where the robot 1700 can operate withoutrunning into problematic positions, like mathematical singularities orjoint limits. Characteristics like Denavit-Hartenberg parameters andlinkage length determined from the Denavit-Hartenberg parameters helpdefine these separate zones. Finally, the region 1706 within thefunctional range 1704, and outside of the full range 1702, representsarea unreachable by the robot 1700.

Dedicated safety zones may also be defined around personnel to helpensure the safety of any person in the operating room as they or dynamicobjects move. The safety zones may have one or more layers. In oneexample, an outer layer (having the greatest distance of the safety zonearound the personnel) is designated as a warning zone, while an innerlayer (having a shorter distance around the personnel than the outerlayer) is designated as an error zone. If any feature of any piece ofequipment enters the warning layer (either by its movement or thepersonnel's movement), the surgical system may be configured to reducethe device's operational speed to avoid collision. If any portion of adevice enters the error layer, then the system may be configured toenter into an emergency stopped state to protect the personnel workingwith the equipment and the patient. Each personnel model can have theability to customize the “Safety Zone.” An Example of these zones can beseen below in FIG. 9. These zones can also be utilized by the AI tools.

With a finalized operating room scene, motion profiles and trajectoriesmay be finally determined and optimized for each robot used in asurgical procedure. For example, as discussed above with respect to thepre-operative planning framework, once the system is aware of therelative positions of each robot (and other objects in the operatingroom), proper trajectories can be determined that avoid collisions andsufficiently and safely perform the designed procedure.

While various features are presented above, it should be understood thatthe features may be used singly or in any combination thereof. Further,it should be understood that variations and modifications may occur tothose skilled in the art to which the claimed examples pertain. Stillfurther, while some aspects described above have been with reference tothe kidney or prostate, it is understood that the features herein may beapplied to any organ, including but not limited to, kidneys, prostates,livers, lungs, hearts, and the like.

What is claimed is:
 1. A method of robotic treatment of a surgicaltarget of a patient's soft tissue organ, the method comprising;obtaining real time intraoperative images of the patient's soft tissueorgan; creating a trajectory plan for a surgical instrument to excise orreconstruct a portion of the surgical target of the patient's softtissue organ; excising the portion of the surgical target using thesurgical instrument and based on the instrument trajectory plan;providing real time deformation data indicating real time deformation ofan external surface of the patient's soft tissue organ with a pluralityof position sensors on the surface of the patient's soft tissue organ;registering the deformation data onto the real time intraoperativeimages; modifying the trajectory plan in real time based on the realtime deformation of the external surface of the patient's soft tissueorgan; and controlling the surgical instrument in real time according tothe modified trajectory plan.
 2. The method of claim 1, whereinmodifying the trajectory plan in real time is a function of both thereal time deformation data and an output of a machine learning systemindicating future deformation during removal of the patient's softtissue organ.
 3. The method of claim 1, further comprising: roboticallypositioning an ultrasound probe; and obtaining the real timeintraoperative images with the ultrasound probe.
 4. The method of claim3, further comprising robotically moving the ultrasound probe in realtime to change a field of view (FOV) of the ultrasound probe.
 5. Themethod of claim 4, wherein the ultrasound probe is moved during asurgical procedure.
 6. The method of claim 5, wherein the ultrasoundprobe is positioned on the surface of the patient's soft tissue organ.7. The method of claim 1, wherein the trajectory plan for the surgicaltarget for the surgical instrument to excise the surgical targetcomprises cutting the surgical target.
 8. The method of claim 1, whereinthe trajectory plan for the surgical instrument to excise the surgicaltarget comprises ablating the surgical target.
 9. The method of claim 1,further comprising: creating a reconstruction trajectory plan toreconstruct the organ.
 10. A method for robotic excising of a surgicaltarget of a patient's soft tissue organ, the method comprising:obtaining real time intraoperative images of the patient's soft tissueorgan; creating an excising plan for a surgical instrument to excise aportion of the surgical target of the patient's soft tissue organ;excising the portion of the surgical target using the surgicalinstrument and based on the excising plan; providing real timedeformation data indicating real time deformation of an external surfaceof the patient's soft tissue organ; registering the deformation dataonto the real time intraoperative images; modifying the excising plan inreal time based on the real time deformation of the external surface ofthe patient's soft tissue organ; and controlling the surgical instrumentin real time according to the modified excising plan.
 11. The method ofclaim 10, wherein the modifying of the excising plan comprises adjustinga trajectory of the surgical instrument.
 12. The method of claim 10,wherein the real time deformation data is obtained with a plurality ofposition sensors on the surface of the patient's soft tissue organ. 13.A robotic surgery system comprising: a surgical robot configured toexcise a portion of a surgical target of a patient's soft tissue organbased on an instrument trajectory plan; a position sensing apparatusconfigured to indicate real time deformation of an external surface ofthe patient's soft tissue organ; a camera configured to obtain real timeintraoperative images of the patient's soft tissue organ; and at leastone controller configured to: determine real time deformationinformation of the external surface of the patient's soft tissue organbased on the position sensing apparatus, register the real timedetermination information to the real time intraoperative images, modifythe trajectory plan in real time based on real time deformation of theexternal surface of the patient's soft tissue organ, and control thesurgical robot in real time according to the modified trajectory plan.14. The system of claim 13, wherein the position sensing apparatuscomprises: a flexible panel deformable in three dimensions to theexternal surface of the patient's organ; and a plurality of spatialtracking sensors secured to the deformable panel.
 15. The system ofclaim 13, further comprising: an ultrasound probe, wherein the camera isan ultrasound camera of the ultrasound probe.
 16. The system of claim13, wherein the position sensing apparatus comprises: at least oneoptical sensor and a stereo-camera system configured to detect theoptical sensor, or an ultrasound transmitter and an ultrasound detectorconfigured to detect the ultrasound transmitter.